Primary mediastinal large B-cell lymphoma

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Badria Munir M.B.B.S.[2] Sowminya Arikapudi, M.B,B.S. [3]

Synonyms and keywords:: Mediastinal B-cell lymphoma; Mediastinal large B-cell lymphoma, PMBCL, Primary mediastinal B-cell lymphoma.

Overview

Primary mediastinal large B-cell lymphoma (PMBCL) is a subtype of diffuse large B-cell lymphoma (DLBCL). It is also considered a distinct type of non-Hodgkin lymphoma (NHL) in the World Health Organization (WHO) classification system. It occurs in the thymus gland. The small gland in the center of the chest behind the sternum where lymphocytes mature, multiply and become T cells. or lymph nodes in the center of the chest. On microscopic histopathological analysis, large-sized cells and alveolar fibrosis are characteristic findings of primary mediastinal large B-cell lymphoma. The incidence of primary mediastinal large B-cell lymphoma increases with age; the median age at diagnosis is 35 years. The symptoms of the primary mediastinal large B-cell lymphoma include fever, weight loss, night sweats, skin rash, facial swelling, cough, shortness of breath, and painless swelling in the neck, axilla, groin, thorax, or abdomen. Lymph node or mediastinal mass biopsy is diagnostic of primary mediastinal large B-cell lymphoma. The predominant therapy for primary mediastinal large B-cell lymphoma is chemotherapy. Adjunctive radiotherapy, stem cell transplant, and biological therapy may be required. The optimal therapy for primary mediastinal large B-cell lymphoma depends on the clinical presentation.

Classification

  • Primary mediastinal B-cell lymphoma was recognized as a sub type of diffuse large B-cell lymphoma since the 1994 in Revised European American Lymphoma Classification.[1]
  • It has been regarded as a unique clinical and biological entity since the 2001 according to World Health Organization classification.[2]

Pathophysiology

Genetics:

  • Genes involved in the pathogenesis of primary mediastinal large B-cell lymphoma include:
    • Comparative genomic hybridzation demonstrated gains in chromosome 9p24 and 2p15
    • Genomic hybridization in chromosome X-p11.4-21
    • Translocations involving the CIITA gene[6]
    • Amplification of the REL oncogene[7]
    • Hyperdiploid karyotypes, often with gains in the region on chromosome 9p containing the JAK2 gene and the genes encoding PD-L1 and PD-L2, ligands for the receptor PD-1[8]
    • The B cell leukemia/lymphoma 2 (BCL-2) gene and B cell leukemia 6 (BCL-6) gene rearrangements can occur.[9]
    • Gains of the proto-oncogene BCL11A and nuclear accumulation of BCL11A(XL) protein.[10]
    • Immunoglobulin genes clonally rearranged.

Immunophenotype:

Microscopic Pathology:

  • On microscopic histopathological analysis, large-sized cells and alveolar fibrosis are characteristic findings of primary mediastinal large B-cell lymphoma.
  • The tumor is composed of large cells with variable nuclear features, cells may resemble:[14][15]
    • Centroblasts
    • Large centrocytes
    • Multilobated cells, often with pale or "clear" cytoplasm
    • Less frequently, the tumor cells resemble immunoblasts
    • Reed-Sternberg-like cells
    • Some cases have also presented with fine, compartmentalizing sclerosis.

Causes

  • There are no established causes of primary mediastinal B-cell lymphoma.

Differentiating ((Page name)) from Other Diseases

Epidemiology and Demographics

Age:

  • The incidence of primary mediastinal large B-cell lymphoma increases with age; the median age at diagnosis is 35 years.[18]

Gender:

  • Females are more commonly affected with primary mediastinal large B-cell lymphoma than males.[18]

Risk Factors

  • There are no established risk factors for primary mediastinal large B-cell lymphoma.

Screening

  • According to the the U.S. Preventive Service Task Force (USPSTF), there is insufficient evidence to recommend routine screening for primary mediastinal large B-cell lymphoma.[19]

Natural History, Complications, and Prognosis

Common complications :

Less common complication :

  • The bone marrow is rarely affected by this type of lymphoma.
  • Recurrence or relapse often occurs in organs or tissues outside the lymph nodes (extranodal sites), such as the kidneys or central nervous system.

Prognosis:

  • Prognosis is generally good after aggressive therapy, which usually combines chemotherapy with mediastinal irradiation. However if relapse occurs , it depends on paucity of molecular level of tumor cells, and their ability to evade immune system.
  • Initial studies suggest that a more favorable course may be predicted by one of the following :
    • Low tumor metabolic activity which is determined by decreased total lesion glycolysis (a measure of FDG uptake) on FDG-PET imaging at baseline or after initial therapy. [20]
    • Further study is needed to confirm the prognostic value of PET before it can be used to modify initial treatment plans.

Diagnosis

Diagnostic Study of Choice

Biopsy:

  • The diagnosis of primary mediastinal large B cell lymphoma relies on the exclusion of adequate tissue, which offers most difficulty due to the location of the tumor, therefore an excisional biopsy is usually not possible.
  • Therefore, surgical biopsy is highly preferred.[21]
  • Due to fibrosis, needle aspirates are often paucicellular and fail to provide information about the tissue.
  • Small biopsies may be non-diagnostic because the lesion is not sampled adequately or because crush artifact or extensive necrosis, fibrosis, or cystic change obscures the diagnostic lesion.
  • Similarly, core biopsies mostly contain fibrotic tissue or tumor cells that are disrupted and not useful.
  • To obtain sufficient tissue for biopsy , patients usually undergo either one of the following techniques:[21]

Staging

  • Staging for primary mediastinal large B-cell lymphoma is provided in the following table:[22]
Revised staging system for primary nodal lymphomas (Lugano classification)
Stage Involvement Extranodal (E) status
Limited
Stage I One node or a group of adjacent nodes Single extranodal lesions without nodal involvement
Stage II Two or more nodal groups on the same side of the diaphragm Stage I or II by nodal extent with limited contiguous extranodal involvement
Stage II bulky II as above with "bulky" disease Not applicable
Advanced
Stage III Nodes on both sides of the diaphragm; nodes above the diaphragm with spleen involvement Not applicable
Stage IV Additional noncontiguous extralymphatic involvement Not applicable

History and Symptoms

Symptoms of the primary mediastinal large B-cell lymphoma include:

Physical Examination

Vitals

Skin

HEENT

Thorax

Abdomen

Extremities

Laboratory Findings

Laboratory tests for primary mediastinal large B-cell lymphoma include:

Electrocardiogram

  • There are no ECG findings associated with primary mediastinal large B-cell lymphoma.

Chest X-Ray

  • Chest X-ray may be helpful in the diagnosis of primary mediastinal large B-cell lymphoma. Finding on chest X-ray suggestive of primary mediastinal large B-cell lymphoma includes large anterior mediastinal mass.[16]

Biopsy

  • Lymph node or mediastinal mass biopsy is diagnostic of primary mediastinal large B-cell lymphoma.

Echocardiography

  • Echocardiography may be helpful in the diagnosis of primary mediastinal large B-cell lymphoma.

CT

CT scan may be helpful in the diagnosis of primary mediastinal large B-cell lymphoma.

MRI

MRI scan may be helpful in the diagnosis of primary mediastinal large B-cell lymphoma.

Other Imaging Findings

  • PET scan may be helpful in the diagnosis of primary mediastinal large B-cell lymphoma.
  • In contrast to CT imaging, FDG-PET is a functional imaging tool that can distinguish between viable tumor and necrosis or fibrosis in a residual mass.[23]

Other diagnostic studies

  • Monoclonal anti-MAL antibody is now commercially used in order to identify primary mediastinal large B-cell lymphoma. It provides good sensitivity and high specificity for diagnosis of primary mediastinal large B-cell lymphoma. [24]

Treatment

Medical Therapy

Treatment of primary mediastinal large B-cell lymphoma[15]
Therapy Description
Chemotherapy
Biological therapy
Radiation therapy
Stem cell transplant
  • A stem cell transplant may be offered to some people if their lymphoma returns or relapses after treatment.
  • The choice of initial treatment depends on stage of disease at the time of presentation. Following are different treatment regimens that are recommended for various stages:

Induction Chemotherapy:

Radiotherapy:

  • Radiotherapy is usually indicated to prevent relapse and recurrence of disease after chemotherapy induction especially after following R-CHOP regimen.[20]
  • In aggressive disease, radiation therapy has been proven to be beneficial in patients with good-prognosis stage I and nonbulky stage II disease.[25]

High-Dose Chemotherapy and Autologous Stem Cell Transplantation:

Relapsed disease:

Salvage therapy:

Surgery

  • Surgical intervention is not recommended for the management of primary mediastinal large B-cell lymphoma.

Primary Prevention

  • There are no established measures for the primary prevention of primary mediastinal large B-cell lymphoma.

Secondary Prevention

  • There are no established measures for the secondary prevention of primary mediastinal large B-cell lymphoma.

References

  1. Harris NL, Jaffe ES, Stein H, Banks PM, Chan JK, Cleary ML, Delsol G, De Wolf-Peeters C, Falini B, Gatter KC (September 1994). "A revised European-American classification of lymphoid neoplasms: a proposal from the International Lymphoma Study Group". Blood. 84 (5): 1361–92. PMID 8068936.
  2. Liu PP, Wang KF, Xia Y, Bi XW, Sun P, Wang Y, Li ZM, Jiang WQ (July 2016). "Racial patterns of patients with primary mediastinal large B-cell lymphoma: SEER analysis". Medicine (Baltimore). 95 (27): e4054. doi:10.1097/MD.0000000000004054. PMC 5058818. PMID 27399089.
  3. Primary mediastinal large B-cell lymphoma. Surveillance, Epidemiology, and End Results Program. http://seer.cancer.gov/seertools/hemelymph/51f6cf56e3e27c3994bd5318/. Accessed on March 7, 2016
  4. Addis BJ, Isaacson PG (April 1986). "Large cell lymphoma of the mediastinum: a B-cell tumour of probable thymic origin". Histopathology. 10 (4): 379–90. PMID 2423430.
  5. Guiter C, Dusanter-Fourt I, Copie-Bergman C, Boulland ML, Le Gouvello S, Gaulard P, Leroy K, Castellano F (July 2004). "Constitutive STAT6 activation in primary mediastinal large B-cell lymphoma". Blood. 104 (2): 543–9. doi:10.1182/blood-2003-10-3545. PMID 15044251.
  6. Steidl C, Shah SP, Woolcock BW, Rui L, Kawahara M, Farinha P, Johnson NA, Zhao Y, Telenius A, Neriah SB, McPherson A, Meissner B, Okoye UC, Diepstra A, van den Berg A, Sun M, Leung G, Jones SJ, Connors JM, Huntsman DG, Savage KJ, Rimsza LM, Horsman DE, Staudt LM, Steidl U, Marra MA, Gascoyne RD (March 2011). "MHC class II transactivator CIITA is a recurrent gene fusion partner in lymphoid cancers". Nature. 471 (7338): 377–81. doi:10.1038/nature09754. PMC 3902849. PMID 21368758.
  7. Joos S, Otaño-Joos MI, Ziegler S, Brüderlein S, du Manoir S, Bentz M, Möller P, Lichter P (February 1996). "Primary mediastinal (thymic) B-cell lymphoma is characterized by gains of chromosomal material including 9p and amplification of the REL gene". Blood. 87 (4): 1571–8. PMID 8608249.
  8. Twa DD, Chan FC, Ben-Neriah S, Woolcock BW, Mottok A, Tan KL, Slack GW, Gunawardana J, Lim RS, McPherson AW, Kridel R, Telenius A, Scott DW, Savage KJ, Shah SP, Gascoyne RD, Steidl C (March 2014). "Genomic rearrangements involving programmed death ligands are recurrent in primary mediastinal large B-cell lymphoma". Blood. 123 (13): 2062–5. doi:10.1182/blood-2013-10-535443. PMID 24497532.
  9. 9.0 9.1 Lamarre L, Jacobson JO, Aisenberg AC, Harris NL (September 1989). "Primary large cell lymphoma of the mediastinum. A histologic and immunophenotypic study of 29 cases". Am. J. Surg. Pathol. 13 (9): 730–9. PMID 2788371.
  10. Weniger MA, Pulford K, Gesk S, Ehrlich S, Banham AH, Lyne L, Martin-Subero JI, Siebert R, Dyer MJ, Möller P, Barth TF (October 2006). "Gains of the proto-oncogene BCL11A and nuclear accumulation of BCL11A(XL) protein are frequent in primary mediastinal B-cell lymphoma". Leukemia. 20 (10): 1880–2. doi:10.1038/sj.leu.2404324. PMID 16871282.
  11. Rodig SJ, Savage KJ, Nguyen V, Pinkus GS, Shipp MA, Aster JC, Kutok JL (February 2005). "TRAF1 expression and c-Rel activation are useful adjuncts in distinguishing classical Hodgkin lymphoma from a subset of morphologically or immunophenotypically similar lymphomas". Am. J. Surg. Pathol. 29 (2): 196–203. PMID 15644776.
  12. Dorfman DM, Shahsafaei A, Alonso MA (December 2012). "Utility of CD200 immunostaining in the diagnosis of primary mediastinal large B cell lymphoma: comparison with MAL, CD23, and other markers". Mod. Pathol. 25 (12): 1637–43. doi:10.1038/modpathol.2012.129. PMID 22899296.
  13. Copie-Bergman C, Plonquet A, Alonso MA, Boulland ML, Marquet J, Divine M, Möller P, Leroy K, Gaulard P (November 2002). "MAL expression in lymphoid cells: further evidence for MAL as a distinct molecular marker of primary mediastinal large B-cell lymphomas". Mod. Pathol. 15 (11): 1172–80. doi:10.1097/01.MP.0000032534.81894.B3. PMID 12429796.
  14. De Paepe P, Achten R, Verhoef G, Wlodarska I, Stul M, Vanhentenrijk V, Praet M, De Wolf-Peeters C (October 2005). "Large cleaved and immunoblastic lymphoma may represent two distinct clinicopathologic entities within the group of diffuse large B-cell lymphomas". J. Clin. Oncol. 23 (28): 7060–8. doi:10.1200/JCO.2005.15.503. PMID 16129841.
  15. 15.0 15.1 Primary mediastinal large B-cell lymphoma. Canadian Cancer Society. http://www.cancer.ca/en/cancer-information/cancer-type/non-hodgkin-lymphoma/non-hodgkin-lymphoma/types-of-nhl/primary-mediastinal-large-b-cell-lymphoma/?region=nb. Accessed on March 7, 2016
  16. 16.0 16.1 16.2 Primary mediastinal large B-cell lymphoma.Hindawi Publishing Corporation. http://www.hindawi.com/journals/crihem/2012/197347/. Accessed on March 07, 2016
  17. "A clinical evaluation of the International Lymphoma Study Group classification of non-Hodgkin's lymphoma. The Non-Hodgkin's Lymphoma Classification Project". Blood. 89 (11): 3909–18. June 1997. PMID 9166827.
  18. 18.0 18.1 Nguyen LN, Ha CS, Hess M, Romaguera JE, Manning JT, Cabanillas F, Cox JD (July 2000). "The outcome of combined-modality treatments for stage I and II primary large B-cell lymphoma of the mediastinum". Int. J. Radiat. Oncol. Biol. Phys. 47 (5): 1281–5. PMID 10889382.
  19. Recommendations. U.S Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/BrowseRec/Search?s=Primary+mediastinal+large+B-cell+lymphoma+. Accessed on March 7, 2016
  20. 20.0 20.1 Martelli M, Ceriani L, Zucca E, Zinzani PL, Ferreri AJ, Vitolo U, Stelitano C, Brusamolino E, Cabras MG, Rigacci L, Balzarotti M, Salvi F, Montoto S, Lopez-Guillermo A, Finolezzi E, Pileri SA, Davies A, Cavalli F, Giovanella L, Johnson PW (June 2014). "[18F]fluorodeoxyglucose positron emission tomography predicts survival after chemoimmunotherapy for primary mediastinal large B-cell lymphoma: results of the International Extranodal Lymphoma Study Group IELSG-26 Study". J. Clin. Oncol. 32 (17): 1769–75. doi:10.1200/JCO.2013.51.7524. PMID 24799481.
  21. 21.0 21.1 Sun W, Song K, Zervos M, Pass H, Cangiarella J, Bizekis C, Crawford B, Wang BY (May 2010). "The diagnostic value of endobronchial ultrasound-guided needle biopsy in lung cancer and mediastinal adenopathy". Diagn. Cytopathol. 38 (5): 337–42. doi:10.1002/dc.21195. PMID 19890836.
  22. Cheson, Bruce D.; Fisher, Richard I.; Barrington, Sally F.; Cavalli, Franco; Schwartz, Lawrence H.; Zucca, Emanuele; Lister, T. Andrew; Alliance, Australasian Leukaemia and Lymphoma Group; Eastern Cooperative Oncology Group; European Mantle Cell Lymphoma Consortium; Italian Lymphoma Foundation; European Organisation for Research; Treatment of Cancer/Dutch Hemato-Oncology Group; Grupo Español de Médula Ósea; German High-Grade Lymphoma Study Group; German Hodgkin's Study Group; Japanese Lymphorra Study Group; Lymphoma Study Association; NCIC Clinical Trials Group; Nordic Lymphoma Study Group; Southwest Oncology Group; United Kingdom National Cancer Research Institute (2014-09-20). "Recommendations for initial evaluation, staging, and response assessment of Hodgkin and non-Hodgkin lymphoma: the Lugano classification". Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology. 32 (27): 3059–3068. doi:10.1200/JCO.2013.54.8800. ISSN 1527-7755. PMID 25113753.
  23. Nagle SJ, Chong EA, Chekol S, Shah NN, Nasta SD, Glatstein E, Plastaras JP, Torigian DA, Schuster SJ, Svoboda J (January 2015). "The role of FDG-PET imaging as a prognostic marker of outcome in primary mediastinal B-cell lymphoma". Cancer Med. 4 (1): 7–15. doi:10.1002/cam4.322. PMC 4312112. PMID 25205600.
  24. Traverse-Glehen A, Pittaluga S, Gaulard P, Sorbara L, Alonso MA, Raffeld M, Jaffe ES (November 2005). "Mediastinal gray zone lymphoma: the missing link between classic Hodgkin's lymphoma and mediastinal large B-cell lymphoma". Am. J. Surg. Pathol. 29 (11): 1411–21. PMID 16224207.
  25. Miller TP, Dahlberg S, Cassady JR, Adelstein DJ, Spier CM, Grogan TM, LeBlanc M, Carlin S, Chase E, Fisher RI (July 1998). "Chemotherapy alone compared with chemotherapy plus radiotherapy for localized intermediate- and high-grade non-Hodgkin's lymphoma". N. Engl. J. Med. 339 (1): 21–6. doi:10.1056/NEJM199807023390104. PMID 9647875.
  26. Haioun C, Lepage E, Gisselbrecht C, Bastion Y, Coiffier B, Brice P, Bosly A, Dupriez B, Nouvel C, Tilly H, Lederlin P, Biron P, Brière J, Gaulard P, Reyes F (March 1997). "Benefit of autologous bone marrow transplantation over sequential chemotherapy in poor-risk aggressive non-Hodgkin's lymphoma: updated results of the prospective study LNH87-2. Groupe d'Etude des Lymphomes de l'Adulte". J. Clin. Oncol. 15 (3): 1131–7. doi:10.1200/JCO.1997.15.3.1131. PMID 9060555.
  27. Cheson BD, Horning SJ, Coiffier B, Shipp MA, Fisher RI, Connors JM, Lister TA, Vose J, Grillo-López A, Hagenbeek A, Cabanillas F, Klippensten D, Hiddemann W, Castellino R, Harris NL, Armitage JO, Carter W, Hoppe R, Canellos GP (April 1999). "Report of an international workshop to standardize response criteria for non-Hodgkin's lymphomas. NCI Sponsored International Working Group". J. Clin. Oncol. 17 (4): 1244. doi:10.1200/JCO.1999.17.4.1244. PMID 10561185.
  28. Popat U, Przepiork D, Champlin R, Pugh W, Amin K, Mehra R, Rodriguez J, Giralt S, Romaguera J, Rodriguez A, Preti A, Andersson B, Khouri I, Claxton D, de Lima M, Donato M, Anderlini P, Gajewski J, Cabanillas F, van Besien K (January 1998). "High-dose chemotherapy for relapsed and refractory diffuse large B-cell lymphoma: mediastinal localization predicts for a favorable outcome". J. Clin. Oncol. 16 (1): 63–9. doi:10.1200/JCO.1998.16.1.63. PMID 9440724.