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 I I I I I I + : + + + + + + + + + + g:+: 1g $ +++ +++ +++ + g o n + + z z = + l Z ++ 1 + +1 + + I + + + + + + ++ , + l : = ++ + , + + + : I : :;Ti++ ++++:: g :+: + +++ + ++ ++ : ++ +I I I I I l I I I ++ ++ ++ ++ ++ + + + + + + + + + + + + + I + + + + + + + + ++ ++ ++ ++ ++ ++ + + + + + + g1g14g I I I lag .--(Yc)bVI(o 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'TCLs.@ 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 l@/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 + . 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