Chapter 105. Malignancies of Lymphoid Cells (Part 21)

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Rare patients with localized early stage mycosis fungoides can be cured with radiotherapy, often total-skin electron beam irradiation. More advanced disease has been treated with topical glucocorticoids, topical nitrogen mustard, phototherapy, psoralen with ultraviolet A (PUVA), electron beam radiation, interferon, antibodies, fusion toxins, and systemic cytotoxic therapy. Unfortunately, these treatments are palliative. Adult T Cell Lymphoma/Leukemia Adult T cell lymphoma/leukemia is one manifestation of infection by the HTLV-I retrovirus. Patients can be infected through transplacental transmission, mother's milk, blood transfusion, and by sexual transmission of the virus. Patients who acquire the virus from their mother through breast milk are most likely to...

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Chapter 105. Malignancies of Lymphoid Cells (Part 21) Rare patients with localized early stage mycosis fungoides can be cured with radiotherapy, often total-skin electron beam irradiation. More advanced disease has been treated with topical glucocorticoids, topical nitrogen mustard, phototherapy, psoralen with ultraviolet A (PUVA), electron beam radiation, interferon, antibodies, fusion toxins, and systemic cytotoxic therapy. Unfortunately, these treatments are palliative. Adult T Cell Lymphoma/Leukemia Adult T cell lymphoma/leukemia is one manifestation of infection by the HTLV-I retrovirus. Patients can be infected through transplacental transmission,
mother's milk, blood transfusion, and by sexual transmission of the virus. Patients who acquire the virus from their mother through breast milk are most likely to develop lymphoma, but the risk is still only 2.5% and the latency averages 55 years. Nationwide testing for HTLV-I antibodies and the aggressive implementation of public health measures could theoretically lead to the disappearance of adult T cell lymphoma/leukemia. Tropical spastic paraparesis, another manifestation of HTLV-I infection (Chap. 181), occurs after a shorter latency (1–3 years) and is most common in individuals who acquire the virus during adulthood from transfusion or sex. The diagnosis of adult T cell lymphoma/leukemia is made when an expert hematopathologist recognizes the typical morphologic picture, a T cell immunophenotype (i.e., CD4 positive), and the presence in serum of antibodies to HTLV-I. Examination of the peripheral blood will usually reveal characteristic, pleomorphic abnormal CD4-positive cells with indented nuclei, which have been called "flower" cells (Fig. 105-10). Figure 105-10
Adult T cell leukemia/lymphoma. Peripheral blood smear showing leukemia cells with typical "flower-shaped" nucleus. A subset of patients have a smoldering clinical course and long survival, but most patients present with an aggressive disease manifested by lymphadenopathy, hepatosplenomegaly, skin infiltration, pulmonary infiltrates, hypercalcemia, lytic bone lesions, and elevated LDH levels. The skin lesions can be papules, plaques, tumors, and ulcerations. Lung lesions can be either tumor or opportunistic infection in light of the underlying immunodeficiency in the disease. Bone marrow involvement is not usually extensive, and anemia and thrombocytopenia are not usually prominent. Although treatment by combination
chemotherapy regimens can result in objective responses, true complete remissions are unusual, and the median survival of patients is ~7 months. Anaplastic Large T/Null Cell Lymphoma Anaplastic large T/null cell lymphoma was previously usually diagnosed as undifferentiated carcinoma or malignant histiocytosis. Discovery of the CD30 (Ki- 1) antigen and the recognition that some patients with previously unclassified malignancies displayed this antigen led to the identification of a new type of lymphoma. Subsequently, discovery of the t(2;5) and the resultant frequent overexpression of the anaplastic lymphoma kinase (ALK) protein confirmed the existence of this entity. This lymphoma accounts for ~2% of all non-Hodgkin's lymphomas. Table 105-10 shows the clinical characteristics of patients with anaplastic large T/null cell lymphoma. The diagnosis of anaplastic large T/null cell lymphoma is made when an expert hematopathologist recognizes the typical morphologic picture and a T cell or null cell immunophenotype with CD30 positivity. Documentation of the t(2;5) and/or overexpression of ALK protein confirm the diagnosis. Some diffuse large B cell lymphomas can also have an anaplastic appearance but have the same clinical course or response to therapy as other diffuse large B cell lymphomas. Patients with anaplastic large T/cell null cell lymphoma are typically young (median age, 33 years) and male (~70%). Some 50% of patients present in stage
I/II, and the remainder with more extensive disease. Systemic symptoms and elevated LDH levels are seen in about one-half of patients. Bone marrow and the gastrointestinal tract are rarely involved, but skin involvement is frequent. Some patients with disease confined to the skin have a different and more indolent disorder that has been termed cutaneous anaplastic large T/null cell lymphoma and might be related to lymphomatoid papulosis.