Composite Lymphocyte-Rich Hodgkin Lymphoma and Peripheral T-Cell Lymphoma Associated With Epstein-Barr Virus

Transcription

1 Composite Lymphocyte-Rich Hodgkin Lymphoma and Peripheral T-Cell Lymphoma Associated ith Epstein-Barr Virus A Case Report and Review of the Literature Steven Sanchez, MD; Houston Holmes, MD; Nora Katabi, MD; Joe Newman, PhD; Rana Domiatti-Saad, PhD; Marvin Stone, MD; George Netto, MD e report a case of a 65-year-old black man with combined Hodgkin lymphoma and T-cell lymphoma. The patient presented with diffuse lymphadenopathy, fever, weight loss, and night sweats. Subsequent biopsy of an axillary lymph node revealed a composite lymphoma composed of classic Hodgkin lymphoma and a peripheral T-cell lymphoma. A needle biopsy of the liver also showed involvement by the composite lymphoma. In situ hybridization studies revealed positive Epstein-Barr virus in Reed- Sternberg cells. Development of T-cell lymphoma following chemotherapy for Hodgkin lymphoma has been reported, but synchronous composite occurrence of both lesions is very rare. Furthermore, this is the first report of such occurrence in a black patient. e present a review of the literature and a discussion of the potential pathophysiologic role of Epstein-Barr virus in the early stages of T-cell lymphomagenesis. (Arch Pathol Lab Med. 2006;130: ) Malignant lymphoma is the fifth most common form of malignancy in the United States. 1 Although more common in developed countries, areas of high incidence of lymphoma exist in parts of the Middle East and Africa. The incidence rates have increased during the last 20 years for non-hodgkin lymphoma (NHL), at least partly the result of improved diagnostic techniques and refined classification schemes. The incidence of Hodgkin lymphoma (HL) has fallen within the last 20 years. According to American Cancer Society estimates for 2005, of the new cases of lymphoma expected to be diagnosed, 11.5% would be HL and 88.5% NHL. 2 It has been estimated that approximately 80% of the NHL group are B-cell derived and only 7.6% are mature T-cell lymphomas. 3 Accepted for publication August 11, From the Departments of Pathology (Drs Sanchez, Katabi, Newman, Domiatti-Saad, and Netto) and Oncology (Drs Holmes and Stone) Sammons Cancer Center, Baylor University Medical Center, Dallas, Tex. The authors have no relevant financial interest in the products or companies described in this article. Corresponding author: George J. Netto, MD, Johns Hopkins Medical Institutions, Pathology and Laboratory Medicine, 401 N Broadway, Room 2242, Baltimore, MD ( gnetto1@jhmi.edu). Reprints not available from the authors. The term composite lymphoma was first proposed to denote the occurrence of more than one histological pattern of lymphoma in a single patient ; however, the term is now used to denote 2 distinct types of lymphoma occurring within a single organ or tissue. 4 Synchronous occurrence of 2 types of NHLs is more common than an NHL and HL. Reports of a B-cell NHL occurring in patients with HL is more common than a concurrent T-cell NHL. 5 The current case is unique in that, to our knowledge, it is the first case to describe lymphocyte-rich classic HL occurring in conjunction with peripheral T-cell lymphoma. In addition, all cases of composite lymphoma reported in the literature occurred in white patients, in contrast to our black male patient. 5 9 Additionally, this case is unusual in that the identical composite lymphoma is also found to involve the liver. REPORT OF A CASE The patient was a 65-year-old black man who presented with multiregional lymphadenopathy (cervical, axillary, and right groin), dysuria, fever, weight loss, and night sweats. The lowgrade fever, night sweats, and 30-lb weight loss had been present for 6 to 7 months. He had no history of major medical illness and he did not have a significant family medical history. He had quit smoking and heavy ethanol use more than 10 years prior to his presentation. He had a past history of heroin use. A complete blood count showed a white blood cell count of 2200/ L, hematocrit of 29.2%, and platelet count of / L. Results of a chemistry panel was normal. A computed tomographic scan confirmed the extensive lymphadenopathy throughout the abdomen and pelvis; the largest nodal mass measured 7 cm and was located in the aortocaval region. Lymphadenopathy was also demonstrated within the pelvic right common iliac chain. The spleen was enlarged to 15 cm in diameter. An open biopsy was performed on 3 axillary lymph nodes measuring up to 2.1 cm. A needle liver biopsy was also obtained. Following histopatholgic diagnosis, the patient received a combination of cyclophosphamide and prednisone followed by an additional course of C- MOPP (cyclophosphamide, vincristine, procarbazine, and prednisone). Despite an initial clinical improvement in the lymphadenopathy, his hepatic functions continued to worsen. The patient died 3 weeks following diagnosis as a result of sepsis and hepatic encephalopathy. An autopsy was not performed. MATERIALS AND METHODS Hematoxylin-esoin sections were obtained from formalin-fixed, paraffin-embedded lymph node and liver biopsies. Immunohis- Arch Pathol Lab Med Vol 130, January 2006 Composite Hodgkin and T-Cell Lymphoma Sanchez et al 107

2 Table 1. Immunohistochemistry and In Situ Hybridization (ISH) Markers and Source* Antibody Dilution Manufacturer CD3 CD20 CD30 CD15 EMA ALK1 CD45 CD5 EBER (ISH) 1:200 1:150 1:20 1:40 1:200 1:25 1:100 1:40 RTU Cell Marque, Hot Springs, Ark DakoCytomation, Carpinteria, Calif DakoCytomation Biocare, Concord, Calif Cell Marque Novocastra Laboratories, Newcastle upon Tyne, United Kingdom DakoCytomation Novocastra Ventana * EMA indicates epithelial membrane antigen; EBER, Epstein-Barr virus encoded RNA; and RTU, ready to use. tochemistry and in situ hybridization studies (Epstein-Barr virusencoded RNA [EBER]) were performed using standard avidinbiotin-peroxidase procedures and a Ventana autostainer (Ventana Medical Systems, Inc, Tucson, Ariz). Appropriate controls were used (Table 1). Flow cytometry analysis was performed using staining panels that included 3 color combinations consisting of CD3, CD5, CD10, CD14, CD19, CD45, and and light chains. Stained cells were run on a FACScaliber (Becton Dickinson, San Jose, Calif) capturing at least cells within the general gated area of interest. Cells were analyzed in CellQuest (BD Biosciences, San Jose, Calif) employing backgating techniques to find particular cell populations of interest and isotypic controls to separate out positive staining cells from negative cells. Gene rearrangement studies were performed using commercial kits (T-cell and B-cell clonality assays, InVivoScribe Technologies, San Diego, Calif). The DNA was extracted from archival formalin-fixed, paraffin-embedded tissue using the QIAamp DNA Mini Kit (Qiagen, Valencia, Calif) according to manufacturer s recommendation. For immunoglobulin heavy-chain gene rearrangement, 3 separate master mixes were used that target all 3 of the conserved framework regions and the joining region within the immunoglobulin heavy gene. For the T-cell receptor chain gene rearrangement, 2 master mixes were used that target multiple variable and joining exon regions within the T-cell receptor chain locus. The polymerase chain reaction (PCR) was performed in a final volume of 50 L in a GeneAmp PCR System 9700 thermocycler (Applied Biosystems, Foster City, Calif). Five microliters of DNA was added to each master mix containing 1.25 U of AmpliTaq Gold polymerase (Applied Biosystems). The amplification reactions were initially heated at 95 C for 10 minutes, then subjected to 35 cycles of 94 C for 30 seconds, 55 C for 30 seconds, and 72 C for 1 minute. The PCR products were extended at 72 C for 10 minutes. The amplification products were resolved by capillary electrophoresis in an ABI 3100 Genetic Analyzer (Applied Biosystems). For this, 1 L of PCR product was mixed with 30 L of deionized formamide containing GeneScan (ROX) size standards (Applied Biosystems). The GeneScan software was used to determine the size of the amplified products. HISTOPATHOLOGIC FINDINGS Axillary Lymph Nodes The lymph node demonstrated effacement of normal architecture by multiple darker nodules separated by lighter diffuse areas (Figure 1, A). On high-power microscopic examination, the darker nodules were composed of small lymphocytes with interspersed large mononuclear Hodgkin cells and classic Reed-Sternberg cells (Figure 1, B). Only rare plasma cells, eosinophils, or neutrophils were present. The overall morphologic features in these areas are those of lymphocyte-rich type of HL. The lighter, diffuse areas separating the described nodules showed infiltration by large lymphocytes with clumped chromatin and inconspicuous nucleoli (Figure 1, C and D). The latter demonstrate increased mitotic activity. Immunohistochemical studies in the nodular areas revealed the expected phenotype of Reed-Sternberg cells (CD30-positive, CD15-positive, and negative reaction to epithelial membrane antigen, ALK1, CD20, and CD45) (Figure 1, E through G). The Reed-Sternberg cells were strongly positive for Epstein-Barr virus (EBV) by in situ hybridization (Figure 1, H). Variable numbers of CD3-positive small lymphocytes were seen surrounding Reed-Sternberg cells in a rosette pattern. However, most of the small lymphocytes within the nodules were CD20-positive. In the diffuse areas separating the nodules, the large lymphocytes were CD3-positive. Flow cytometry analysis demonstrated an abnormal population of CD3 T cells with loss of pan T-cell marker CD5 (Figure 2). No light-chain restriction in B-cell population was detected by flow cytometry. Gamma T-cell receptor gene rearrangement studies revealed a clonal population of T cells (Figure 3). No evidence of immunoglobulin heavy-chain gene rearrangement was on clonality assay. Liver Portal areas of the liver biopsy showed 2 distinct populations of neoplastic cells. Their morphologic and immunophenotypic features support involvement by composite lymphoma identical to that described in the axillary lymph node (Figure 4, A and B). The cells with Reed- Sternberg cell features were positive for CD30 (Figure 4, C) and weakly positive for CD15, and they were negative for CD20 and CD45. The large cell (T-cell) population was positive for CD3 (Figure 4, D) and lacked CD5 positivity. The EBER in situ hybridization for EBV was again positive in the Reed-Sternberg cells. Gene rearrangement studies performed on paraffin tissue of the liver biopsy revealed a clonal T-cell population with an identical size of PCR product of the T-cell receptor gene in both axillary and Figure 1. A, Section of lymph node showing the interface between darker nodular area (lower left) and lighter diffuse area (upper right) representing the Hodgkin lymphoma (HL) and the peripheral T-cell lymphoma (PTL), respectively. Arrowheads point to Reed-Sternberg (HRS) cells (hematoxylin-eosin, original magnification 100). B, Lymph node section demonstrating the HL component containing Reed-Sternberg cells (hematoxylin-eosin, original magnification 400). C, Hematoxylin-eosin section of lymph node demonstrating the PTL component composed of a diffuse population of large cells (original magnification 400). D, Diffuse CD3-positive staining in PTL component (original magnification 400). E and F, The HRS cells demonstrating membranous and Golgi pattern of staining with anti-cd30 and anti-cd15, respectively (original magnifications 400). G, The CD20-negative HRS cells in a background of CD20-positive small B-lymphocytes (immunohistochemistry, original magnification 400). H, The HRS cells showing positive nuclear reactivity for Epstein-Barr virus encoded RNA (EBER) (in situ hybridization for Epstein- Barr virus, original magnification 400). 108 Arch Pathol Lab Med Vol 130, January 2006 Composite Hodgkin and T-Cell Lymphoma Sanchez et al

3 Arch Pathol Lab Med Vol 130, January 2006 Composite Hodgkin and T-Cell Lymphoma Sanchez et al 109

4 Figure 2. Histogram demonstrating flow cytometry analysis. A predominant CD3-positive/CD5-negative population is found in the R2 region of intermediate-sized cells. Intermed indicates intermediate; FSC, forward scatter; Per CP, peridinin chlorophyll protein; UL, upper left; UR, upper right; LL, lower left; LR, lower right; PE, phycoerythrin; and FITC, fluorescein isothiocyanate. Figure 3. T-cell receptor (TCR) gene rearrangement assay results. From top to bottom: Lines 1 and 2 show the polyclonal and monoclonal controls of the assay. Lines 3 and 4 demonstrate the presence of a clonal T-cell population in paraffin tissue from the axillary lymph node and liver, respectively. Note the identical size of T-cell receptor (TCR) gene polymerase chain reaction (PCR) product, suggesting a clonal relation of the monoclonal populations in both samples. hepatic biopsies, strongly suggesting clonal relation among the 2 T-cell lymphomas (Figure 3). COMMENT The term composite lymphoma was first proposed to denote the occurrence of more than 1 lymphoma in a single patient; however, the term is now reserved to denote the rare concurrent occurrence of 2 distinct types of lymphoma within a single organ or tissue. 4 The occurrence of 2 NHLs is more common than that of an NHL and an HL. 1 Reports of a B-cell NHL occurring in patients with HL is more common than a concurrent T-cell NHL. 5 Composite HL and T-cell lymphoma is an entity that has been rarely reported. Our review of the literature found only 6 previous cases of composite lymphoma composed of HL and T-cell lymphoma (Table 2). 5 8 Many cases of patients with both T-cell lymphoma and HL reported in the literature do not fit the strict definition currently being used to define a composite lymphoma because they describe a T-cell lymphoma that occurred at separate sites and/or at different points in time. Three of the 6 previously described cases of composite lymphoma harbor the nodular lymphocyte-predominant type of HL. 5 The remaining 3 cases describe the HL component belonging to the classic type. 6 8 Specifically, our case has lymphocyterich classic HL. To our knowledge, this case is the first report of a composite classic HL and peripheral T-cell lymphoma developing in a black patient. An interesting observation described by Quintanilla- Martinez et al 9 is the presence of the so-called Reed-Sternberg-like cells that may occur in T-cell lymphoma. These Reed-Sternberg-like cells have the typical morphologic features of prominent eosinophilic nucleoli and abundant cytoplasm. They are reportedly negative for all T-cell markers and in some cases positive for CD20. In all cases, the Reed-Sternberg-like cells were positive for CD30, CD15, EBV-latent membrane protein 1, and EBER. It is important to recognize this mimicker of HL so as not to diagnose such lesions as a composite Hodgkin and T-cell lymphoma. In our case, this did not pose difficulty because in the lymphocyte-rich classic HL, the Reed-Sternberg cells occurred in separate, scattered nodules consisting mostly of small B cells in which scattered Reed-Sternberg cells were found. Another interesting aspect of the current case was the simultaneous presence of both elements of the composite neoplasm in the liver tissue as well as in the axillary lymph nodes. As illustrated here, we were able to demonstrate an identical-sized PCR product of the T-cell receptor gene in both axillary and hepatic biopsies, strongly 110 Arch Pathol Lab Med Vol 130, January 2006 Composite Hodgkin and T-Cell Lymphoma Sanchez et al

5 Figure 4. A, Liver biopsy showing involvement of portal tract by the composite lymphoma (hematoxylin-eosin, original magnification 100). B, Reed-Sternberg cells in a portal tract. Note peripheral T-cell lymphoma (PTL) cells in background (hematoxylin-eosin, original magnification 400). C, Portal tract showing Reed-Sternberg cells with positive CD30 reactivity (original magnifications 400). D, Portal tract showing background PTL cells with CD3-positive reactivity (immunohistochemistry, original magnification 200). Table 2. Prior and Current Reported Cases of Composite T-Cell and Hodgkin Lymphoma* Age, y/sex Race HL Type T-Cell Lymphoma Source, y 31/M 51/M 26/M 65/M 88/F 81/F 65/M? B NLP NLP NLP 4 y posttreatment for HL Delabie et al, Delabie et al, Delabie et al, Niedobitek et al, Bee et al, Steinhoff et al, Current case, 2005 * HL indicates Hodgkin lymphoma; NLP, nodular lymphocyte-predominant Hodgkin lymphoma; and, classic Hodgkin lymphoma. suggesting a clonal relation among the T-cell lymphoma components. The pathogenesis of composite lymphomas is more difficult to explain in cases of an HL and a T-cell lymphoma as opposed to an HL and a B-cell lymphoma or 2 different types of B-cell lymphomas. Common explanation of the latter occurrence is clonal progression of malignant B cells through mutational accumulation, and progression into a more aggressive, higher grade neoplastic B-cell process. An example would be Richter syndrome of B-cell small lymphocytic lymphoma transforming into a high-grade, diffuse, large B-cell lymphoma with coexistence of both processes. Because neoplastic Reed-Sternberg cells are, in most cases, a type of B-lymphocyte, a similar logic of progression among an HL and a coexisting B-cell NHL would be conceivable. On the other hand, the development of a T-cell lymphoma in the setting an HL or a B-cell lymphoma raises the possibility of some cooperative process between T-lymphocytes and B-lymphocytes that favored neoplasia. In a case such as our current report, in which an infectious agent (EBV) is identified, the theory of multilineage, Arch Pathol Lab Med Vol 130, January 2006 Composite Hodgkin and T-Cell Lymphoma Sanchez et al 111

6 cooperative, reactive processes driving progression to lymphoma becomes even more conceivable. Although EBV preferentially infects B cells, it may also infect T cells. Infection of T cells is through the C3d (CR2/CD21) receptor found on developing T cells, but not mature circulating T cells. 10 InareportbyHoetal, 11 EBV-infected cells were found in 52% of peripheral T-cell lymphomas. However, in the majority of EBV-positive cases (77%), only a few of the tumor cells were infected. In their remaining peripheral T-cell lymphoma cases, more than half of tumor cells were infected. Double-staining was used to evaluate lineage in the infected cells. The EBV-positive cells were shown to be CD20-positive more often than CD3-positive. The CD3-posivitve/EBER-positive cells were 1% of the total EBER-positive cells. In the same cases, CD20-positive/EBER-positive cells comprised 10% or more, and in 6 of the 11 cases, they comprised 50% or more of all EBERpositive cells. Curiously, in 5 of the 11 successfully doublestained cases, 50% of the EBER-positive cells expressed neither CD20, CD3, nor CD45RO reactivity. The latter may be caused by downregulation of cellular markers related to the viral infection. Subsequent studies have confirmed by double-labeling immunohistochemistry that most of the EBV-positive cells in HL and T-cell lymphoma are CD20-positive. 11 The occurrence of combined HL and T-cell lymphoma could be a totally coincidental existence of 2 independent de novo neoplastic processes of 2 separate cases of histogenesis. However, it is possible that 1 of the 2 processes could have existed first and had a role in the oncogenesis of the second type of lymphoma. At this point, one can only theorize on the different pathogenic possibilities for the development of such composite lymphomas. In our case, one possible scenario would be malignant transformation of a preexisting reactive T-cell population. Such reactive T-cell population/clone could have developed in response to a preexisting B-cell infectious or neoplastic process, for example, neoplastic EBV-positive Reed-Sternberg cells. Such theory is evidently supported by the fact that infected as well as neoplastic B-lymphocytes are capable of altering T-cell growth through the production of cytokines and by expressing T-cell directed growth stimulatory molecules. 10,12 A second possibility that could explain a combined HL/peripheral T-cell lymphoma such as ours may be the occurrence of a T-cell neoplasm first that, in turn, recruited a host B-cell response. The latter, potentially with a pathogenic role for EBV, 10 could have undergone a neoplastic transformation and led to the formation of the HL component. Future studies examining the clonal evolution of such combined lymphomas are needed to further shed light on these intriguing rare entities. References 1. Ioachim HL, Ratech H. Ioachim s Lymph Node Pathology. 3rd ed. Philadelphia, Pa: Lippincott illiams & ilkins; 2002: American Cancer Society. Cancer Facts and Figures Atlanta, Ga: American Cancer Society; Stewart B, Kleihues P. orld Cancer Report. Lyon, France: IARC Press; 2003: Thirumala S, Esposito M, Fuchs A. An unusual variant of composite lymphoma. Arch Pathol Lab Med. 2000;124: Delabie J, Greiner TC, Chan C, et al. lymphocyte predominance Hodgkin s disease and T-cell lymphoma. A report of three cases. Am J Surg Pathol. 1996;20: Niedobitek G, Baumann I, Brabletz T, et al. Hodgkin s disease and peripheral T-cell lymphoma: composite lymphoma with evidence of Epstein-Barr virus infection. J Pathol. 2000;191: Bee CS, Blaise YP, Dunphy. Composite lymphoma of Hodgkin lymphoma and mycosis fungoides: previously undescribed in the same extracutaneous site. Leuk Lymphoma. 2001;42: Steinhoff M, Hummel M, Orfanos CE, et al. Cutaneous T cell lymphoma and classic Hodgkin lymphoma of the B cell type within a single lymph node: composite lymphoma. J Clin Pathol. 2004;57: Quintanilla-Martinez L, Fend F, Jaffe ES, et al. Peripheral T-cell lymphoma with Reed-Sternberg-like cells of B-cell phenotype and genotype associated with Epstein-Barr virus infection. Am J Surg Pathol. 1999;23: Jones JF, Shurin S, Sklar J, et al. T-cell lymphomas containing Epstein-Barr viral DNA in patients with chronic Epstein-Barr virus infections. New Engl J Med. 1988;313: Ho J, Ho F, Chan A, et al. Frequent detection of Epstein-Barr virus-infected B cells in peripheral T-cell lymphomas. J Pathol. 1998;185: Bishop GA, Hostager BS. The CD40-CD154 interaction in B cell-t cell lesions. Cytokine Growth Factor Rev. 2003;14: Arch Pathol Lab Med Vol 130, January 2006 Composite Hodgkin and T-Cell Lymphoma Sanchez et al