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The Oncologist, Vol. 11, No. 8, 923-928, September 2006; doi:10.1634/theoncologist.11-8-923
© 2006 AlphaMed Press

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Lymphoma

Disseminated Intravascular B-Cell Lymphoma: Clinicopathological Features and Outcome of Three Cases Treated with Anthracycline-Based Immunochemotherapy

Maria Bouzania, Themis Karmirisa, Dimitra Rontogiannib, Susanna Delimpassia, John Apostolidisa, Maria Mpakiria, Emmanuel Nikiforakisa

a Department of Hematology and Lymphoma and b Department of Histopathology, Evangelismos Hospital, Athens, Greece

Key Words. Extranodal lymphoma • Intravascular lymphoma • Immunochemotherapy

Correspondence: Maria Bouzani, M.D., Department of Hematology and Lymphoma, Evangelismos Hospital, 45-47 Ipsilandou Street, Athens 106 76, Greece. Telephone: 30-2107201103; Fax: 30-2107662850; e-mail: bouzani{at}otenet.gr

Received June 12, 2006; accepted for publication June 20, 2006.


   ABSTRACT
Top
 Abstract
Introduction
 Case 1
 Case 2
 Case 3
 Discussion
 Disclosure of Potential...
 References
 
The purpose of this study was to evaluate the use of combination anthracycline-based immunochemotherapy in intravascular lymphoma (IVL). This is an extremely rare, disseminated, and aggressive extranodal CD20+ non-Hodgkin’s lymphoma (NHL) with poor outcome following anthracycline-based chemotherapy. From a population of 700 newly diagnosed patients with NHL who were registered and followed up at our unit between 1990 and 2005, three cases (0.4%) have been classified as IVL. Among the patients, there were two men and one woman, with a median age of 52 years. We have assessed the clinicopathological characteristics, response to therapy, and outcome. All patients presented with systemic symptoms and disseminated disease. All patients received anthracycline-based chemotherapy in combination with the anti-CD20 monoclonal antibody rituximab (immunochemotherapy). Complete remission was achieved in all three patients, and currently all remain progression free with a follow-up of 24–45 months. In conclusion, anthracycline-based immunochemotherapy induces durable remissions in patients with IVL, an ultimately fatal disease, suggesting that the clinical course of this disease may be altered with immunochemotherapy.


   INTRODUCTION
Top
 Abstract
 Introduction
Case 1
 Case 2
 Case 3
 Discussion
 Disclosure of Potential...
 References
 
Intravascular lymphoma (IVL) is a very rare subtype of extranodal diffuse large B-cell lymphoma (DLBCL). This entity was initially considered as an endothelial neoplasm, but with the advent of immunohistochemical studies, the lymphoid origin of this peculiar disease was established, imposing its reclassification as angioendotheliotropic lymphoma (Kiel), angiotropic large cell lymphoma (Lukes–Collins), and unclassified large B-cell lymphoma in the Revised European American Lymphoma (REAL) Classification [1–3].

In the current World Health Organization (WHO) classification, IVL is recognized as a unique disease entity [4]. It is an extremely rare extranodal lymphoma of B-cell origin, proliferating in the lumina of small vessels, particularly capillaries, while the parenchyema of the involved organs is spared. In some cases, fibrin thrombi may be seen in the vascular lumen. In view of the rarity of the disease, epidemiologic data are only available through collaborative study group registries [5]. It usually affects middle-aged or elderly subjects and follows a wide pattern of dissemination in extranodal sites, while nodal involvement is considered rare. Noteworthy is the tropism of IVL for the central nervous system (CNS) and the skin [6]. Virtually any organ can be involved, including the kidneys, adrenals, heart, liver, spleen, gastrointestinal tract, lungs, and genitourinary tract [5–9], while the bone marrow is infiltrated in a third of cases [5]. Thus the occlusion of small vessels by tumor cells results in clinical manifestations that are highly variable, including pyrexia, dementia, cutaneous nodules or plaques, and occasionally breathlessness, hypertension, adrenal failure, hematologic abnormalities (autoimmune hemolytic anemia, leukopenia, pancytopenia, disseminated intravascular coagulation), and markedly elevated lactate dehydrogenase (LDH) [5, 8–10]. Interestingly, a "cutaneous variant," limited exclusively to the skin, has been described and included in the recent WHO-European Organization for Research and Treatment of Cancer (EORTC) classification for cutaneous lymphomas [11]. This variant is mainly confined to woman and has a better prognosis than disseminated disease [5].

In view of the variety of the clinical manifestations and the rarity of the disease, it is frequently misdiagnosed. This is the reason why the majority of cases have been diagnosed postmortem and reports studying the clinical course and outcome of the disease following chemotherapy are limited to retrospective data from study groups [12]. In our department, among 700 patients with non-Hodgkin’s lymphoma registered and followed up during the past 15 years, three have been diagnosed as IVL. We have reviewed the clinical features, the histopathologic profile, and the outcome of these patients following treatment with immunochemotherapy. The information used in this analysis was obtained through a retrospective chart review approved by the local institutional review board.

Although limited in number of patients, this is the largest report to date suggesting that the addition of the anti-CD20 antibody rituximab (Rituxan®; Biogen IDEC, Inc., and Genentech, Inc., South San Francisco, CA) to combination chemotherapy induces sustainable remissions in this rare and fatal disease.


   CASE 1
Top
 Abstract
 Introduction
 Case 1
Case 2
 Case 3
 Discussion
 Disclosure of Potential...
 References
 
A 52-year-old man, seropositive for hepatitis B virus (HBV), was admitted to our department with fever, pancytopenia, and splenomegaly. On physical examination, there was right inguinal lymphadenopathy and massive splenomegaly (20 cm below the left costal margin). There was no clinical evidence of hepatic failure or portal hypertension. The full blood count was abnormal with leukopenia (WBC, 3,950/µl; absolute neutrophil count [ANC], 1,890/µl), anemia (hematocrit [Ht], 28%), and severe thrombocytopenia (platelet count, 17,000/µl). Routine blood chemistry revealed a markedly elevated LDH level of 2,157 U/l (normal range, 240–460 U/l) and ß2-microglobulin level of 4,819 µg/l (normal range, 700–1,800 µg/l). Routine hepatic liver function tests included: alanine aminotransferase (ALT), 26 U/l; aspartate aminotransferase (AST), 40 U/l; alkaline phosphatase, 96 U/l; total bilirubin, 1.3 mg/dl; albumin, 4.2 g/dl; prothrombin time (PT), 12.6 seconds; and partial thromboplastin time (PTT), 32 seconds. Serological tests revealed negative antibodies for HIV and hepatitis C virus (HCV), while serological tests for HBV demonstrated a positive surface HBV antigen (HbsAg), negative HBV envelope antigen (HBeAg), and positive anti-HBV core antibody (HBcAb). HBV DNA levels were not determined.

A lymph node biopsy demonstrated a pattern of reactive lymphadenitis with histiocytosis and vascular transformation of sinusoids. The trephine marrow biopsy (Fig. 1Go) demonstrated an intravascular infiltrate of moderate to large-sized lymphoid cells with fine chromatin and a moderate amount of cytoplasm. Immunophenotypically, these cells expressed the B-cell–associated antigens CD19, CD20, and CD22, with an absence of CD5, CD10, CD30, CD3, CD25, and CD123 antigens. Staging computed tomography (CT) scans of the chest, abdomen, and pelvis demonstrated splenomegaly and no other apparent sites of disease. The cerebrospinal fluid (CSF) was negative. Thus the stage of the disease was evaluated as IVB. The patient was treated with the combination of CHOP (cyclophosphamide, 750 mg/m2 body surface area on day 1; doxorubicin, 50 mg/m2 on day 1; vincristine, 1.4 mg/m2 on day 1; and prednisolone, 50 mg/m2 on days 1–5) and the anti-CD20 antibody rituximab (375 mg/m2) delivered on day 1 of each cycle. CNS prophylaxis was also delivered, consisting of an intrathecal (IT) infusion of 15 mg of methotrexate administered on day 1 of each of the first four cycles of treatment. Following restaging after four cycles of treatment, there was no detectable disease on a repeat marrow trephine biopsy, and the spleen was of normal size. The patient completed eight cycles of treatment and remained progression free at 45 months from the initiation of treatment. Pre-emptive treatment to prevent reactivation of HBV was initiated with the antiviral agent lamivudine (Zeffix® tablets; GlaxoSmithKline, plc., Brentwood, U.K.) at a dose of 100 mg daily starting 1 week before immunochemotherapy. Serial liver function tests were measured prior to each cycle of treatment and at monthly intervals thereafter. Lamivudine was discontinued 6 months following completion of treatment. There has been no evidence of hepatic disease reactivation during the patient’s follow-up.


Figure 1
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  		Figure 1. Bone marrow (case 1): distended sinus (solid arrow) with intrasinusoidal growth of large lymphoid cells (dashed arrow) (H & E x 400).

 

   CASE 2
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 Abstract
 Introduction
 Case 1
 Case 2
Case 3
 Discussion
 Disclosure of Potential...
 References
 
A 69-year-old woman presented with a 3-month history of fever and fatigue. Clinical examination revealed a 3-cm pigmented cutaneous plaque on the right leg and mild hepatomegaly. She was febrile and there was no sign of neurological involvement. The full blood count showed mild pancytopenia (WBC, 3,010/µl; ANC, 1,560/µl; Ht, 32.9%; platelet count 84,000/µl). The direct and indirect Coombs reactions were negative. The LDH level was 4,117 U/l and ß2-microglobulin was 4,020 µg/l. A cutaneous biopsy (Fig. 2Go) demonstrated obstruction of the small vessels (capillaries, veinules, arterioles) of the skin and s.c. tissue by large neoplastic lymphoid cells, with vesicular nuclei with prominent nucleoli. They expressed leukocyte common antigen (CD45) and the B-cell-associated antigens CD19, CD20, and CD22 but not CD3, CD5, or CD30. In addition, the trephine biopsy revealed infiltration of the sinuses of the bone marrow in a similar pattern as the cutaneous lesions. Whole-body CT was unremarkable. Examination of the CSF was negative. The patient was assessed as Ann Arbor stage IVB and treated with CHOP chemotherapy and the anti-CD20 antibody rituximab, while CNS prophylaxis with IT methotrexate was administered on day 1 each of the first four cycles. Following four cycles of immunochemotherapy, the cutaneous plaque was not visible, and there was no evidence of disease on a repeat trephine biopsy. The patient received an additional two cycles of immunochemotherapy (six cycles in total) and remained progression free 35 months from treatment initiation.


Figure 2
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  		Figure 2. Skin biopsy (case 2): Endothelial cells of the vascular wall (solid arrow), intravascular pattern of growth of large lymphoid cells (dashed arrow), thrombosis of the lumen with fibrin thrombi (open arow) (H & E x 400).

 

   CASE 3
Top
 Abstract
 Introduction
 Case 1
 Case 2
 Case 3
Discussion
 Disclosure of Potential...
 References
 
This is the case of a 52-year-old man referred to our unit with fever, pancytopenia, and splenomegaly. The patient was seropositive for HBV, with no clinical evidence of hepatic disease. Clinical examination revealed massive splenomegaly without peripheral lymphadenopathy. Staging CT of the chest, abdomen, and pelvis confirmed the findings of the physical examination. The blood tests revealed mild pancytopenia (WBC, 2,600/µl; ANC, 1,590/µl; Ht, 35.2%; hemoglobin, 11.5 g/dl; platelet count, 76,000/µl), and elevated levels of LDH (680 U/l) and ß2-microglobulin (3,000 µg/l). Routine hepatic liver function tests included: ALT, 30 U/l; AST, 47 U/l; alkaline phosphatase, 102 U/l; total bilirubin, 1.1 mg/dl; albumin, 4.0 g/dl; PT, 12.8 seconds, and PTT, 39 seconds. Serological tests revealed negative antibodies for HIV and HCV, while serological tests for HBV demonstrated positive HbsAg, negative HBeAg, and positive anti-HBV core antibody (HBcAb). HBV DNA levels were undetectable with real-time quantitative polymerase chain reaction (PCR).

A trephine biopsy was unremarkable, and thus the patient underwent splenectomy and hepatic biopsies simultaneously: the splenic (Fig. 3Go) and hepatic intrasinusoidal demonstrated infiltration by moderate to large-sized lymphoid cells with fine chromatin and rather prominent nucleoli. The immunophenotype revealed positivity of the tumor cells for CD20 antibody (Fig. 4Go), while CD5, CD10, CD23, CD25, and CD30 antigens were negative. The stage was evaluated as IVB. Splenectomy was of benefit for this patient; a few weeks later, his full blood count had returned to normal values, and B symptoms resolved prior to the initiation of treatment. The patient received six cycles of CHOP chemotherapy plus rituximab and CNS prophylaxis with IT methotrexate. The patient remained progression free at 24 months following treatment initiation. Preemptive treatment with lamivudine, 100 mg daily starting 1 week before immunochemotherapy, was also administered to this patient. Serial liver function tests were performed prior to each cycle of treatment and at monthly intervals during follow-up. Repeat HBV DNA levels were measured 6 weeks following the completion of treatment, and a very low viral load with real-time PCR (<200 copies/ml) was detected. Lamivudine was discontinued 6 months following the completion of treatment. There was no evidence of hepatic disease reactivation during the patient’s follow-up.


Figure 3
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  		Figure 3. Spleen (case 3). Large B cells with an intrasinusoidal pattern of growth (arrow) (H & E x 400).

 

Figure 4
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  		Figure 4. Spleen (case 3): Intrasinusoidal growth of large B lymphoid cells highlighted by immunohistochemical expression of CD20 (x 400).

 

   DISCUSSION
Top
 Abstract
 Introduction
 Case 1
 Case 2
 Case 3
 Discussion
Disclosure of Potential...
 References
 
IVL is a distinct, extremely rare, extranodal subtype of DLBCL characterized by an aggressive clinical course and poor outcome. There is no controlled prospective study of response to various therapies, and treatment recommendations are based largely on anecdotal experience and retrospective data. Currently, there are no standard guidelines concerning the optimal therapeutic approach for this uncommon disease. According to a retrospective International Extranodal Lymphoma Study Group (IELSG) report of 35 patients with IVL, 22 were treated with chemotherapy (anthracycline based in 18 patients) with an overall response rate of 59% and a median time to treatment failure of 8 months [12]. The 3-year event-free and overall survival rates in that series were 27% and 33%, respectively. Of note is that 7 of these 22 patients (32%) had disease limited to the skin (cutaneous variant), which is associated with a favorable outcome. Among the eight surviving patients in this series, three had the cutaneous variant and two had stage I disease. So these results do not reflect the poorer outcome of patients with disseminated IVL. In a report by the IELSG, with particular emphasis on the cutaneous variant, while the overall survival of patients with the cutaneous variant had not been reached after a median observation time exceeding 24 months, the overall survival time of patients with disseminated IVL was <12 months, reflecting the dismal outcome of patients with disseminated disease [5]. These results are markedly inferior to those reported in patients with advanced stage aggressive non-Hodgkin’s lymphoma, given that standard CHOP produces a progression-free survival rate of 43% at approximately 3 years in these patients [13]. Hence, standard CHOP is inadequate in disseminated IVL, and patients are eligible for novel treatment strategies.

The addition of rituximab to standard chemotherapy has had a major impact on the treatment of aggressive B-cell lymphomas. Currently, immunochemotherapy with the combination of CHOP plus rituximab is considered the gold standard for the treatment of DLBCL [14, 15]. Given that neoplastic cells of IVL strongly express the CD20 antigen, they are therefore a target for immunotherapy. Consequently, our patients were treated with immunochemotherapy (Table 1Go). All three patients achieved complete remission following six to eight cycles of treatment and remain progression free at 45, 35, and 25 months, respectively. Our experience is consistent with the studies maintaining that patients with IVL who receive systemic anthracycline-based chemotherapy may achieve complete remission. The addition of rituximab to anthracycline-based chemotherapy has been evaluated in three case reports exclusively of the cutaneous variant of IVL [16–18]. Sustainable remission has also been described in a case report of single-agent rituximab in disseminated IVL [19]. Our report is the largest to date evaluating the therapeutic impact of anthracycline-based immunochemotherapy exclusively in disseminated IVL. Although it is rather premature to come to safe conclusions, our excellent results suggest that the addition of the anti-CD20 antibody rituximab to traditional anthracycline-based chemotherapy (CHOP) has an impact on the clinical course of the disease. With a follow-up of 24–45 months, all three patients remain progression free, a very promising observation.


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  		Table 1. Patient characteristics and treatment outcome

 
Our institutional standard practice includes CNS prophylaxis with IT methotrexate to all patients with diffuse large-cell lymphoma with more than one extranodal site, or who are at high risk according to the International Prognostic Index [20]. Additionally, patients with IVL are intrinsically at high risk for CNS involvement at presentation or at relapse, justifying the use of systemic CNS prophylaxis in this disease entity irrespective of stage at diagnosis. Although all three of our patients demonstrated no evidence of CNS disease, they received CNS prophylaxis with IT methotrexate on day 1 of the first four cycles of treatment.

Interestingly, two of our patients were HBV carriers (HBsAg positive) and presented at diagnosis with splenomegaly. Although epidemiological evidence strongly suggests a link between chronic infection with HCV and primary extranodal B-cell lymphomas (especially of the liver, spleen, and salivary glands) [21], the etiologic role of HBV in the induction of B-cell lymphomas remains controversial [22].

Another important issue regarding HBV relates to the high risk for reactivation of HBV infection in HBV-carrying lymphoma patients during cytotoxic or immunosuppressive therapy, with hepatitis B occurring in 49% of HBsAg-positive patients is this setting [23]. The combination of CHOP and rituximab is being increasingly used in the treatment of non-Hodgkin’s lymphomas, and rituximab-induced B-cell depletion has been linked to fatal fulminant hepatitis in HBsAg carriers and, previously, HBsAg-negative patients with high titers of antibodies against HBsAg [24, 25]. Hepatic complications involve the so called "rebound phenomenon," based on the observation that hepatic damage is exaggerated following completion of treatment. During the period of immunosuppression from cytotoxic therapy, new or increased viral replication occurs, while when cytotoxic therapy is discontinued, immunocompetence is partially restored and rebound CD8+ cytotoxic T-lymphocyte recovery leads to rapid destruction of infected hepatocytes (hepatitis). Lamivudine has been found to effectively suppress HBV replication in immunosuppressed patients, was initiated in our two HBV carrier patients 1 week prior to the initiation of immunochemotherapy, and was discontinued 6 months following completion of treatment. In case 3, the HBV viral load 6 weeks following withdrawal of immunochemotherapy was very low, while liver function tests remained normal in both cases during and following completion of immunochemotherapy. Preemptive lamivudine is strongly recommended in HBsAg-positive patients receiving cytotoxic chemotherapy and/or rituximab, and patients should be monitored closely for HBV reactivation during and after withdrawal of lamivudine.

In summary, we have reported our experience concerning the clinical course, the pathologic findings, and the outcome of three patients with disseminated IVL who were treated at a single center with immunochemotherapy. The combination of anthracycline-base chemotherapy and rituximab produces durable remissions and most likely prolongs survival for patients with this rare and aggressive disease. Longer observation and prospective study group data are needed to confirm these results.


   DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST
Top
 Abstract
 Introduction
 Case 1
 Case 2
 Case 3
 Discussion
 Disclosure of Potential...
References
 
The authors indicate no potential conflicts of interest.


   REFERENCES
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 Abstract
 Introduction
 Case 1
 Case 2
 Case 3
 Discussion
 Disclosure of Potential...
 References
 

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