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Case of the Month
Case of the Month
ALK- positive, anaplastic large cell lymphoma with involvement of the adrenal gland
ALK- positive, anaplastic large cell lymphoma with involvement of the adrenal gland
Contributed by: Gautham Shankar and Khushboo Tekriwal
Contributed by: Gautham Shankar and Khushboo Tekriwal
Introduction:
Introduction:
ALK- positive Anaplastic large cell lymphoma is a peripheral T cell lymphoma usually consisting of large lymphoid cells with abundant amphophilic cytoplasm, often horseshoe shaped nuclei, an ALK (anaplastic lymphoma kinase) gene translocation and expression of ALK protein and CD30 (1). Systemic or diffuse anaplastic large cell lymphoma is a non-Hodgkin lymphoma (NHL) of T-cell or null lineage, characterized by proliferation of pleomorphic cells with strongly and uniformly CD30 positivity. Anaplastic large cell lymphoma (ALCL) originates from peripheral T-lymphocytes and is the most common mature T-cell neoplasm in children and adolescents. All in all, these neoplasms are relatively rare among all types of lymphomas. ALCL comprises about 10-20% of all non-Hodgkin lymphomas (NHL) in the above group of patients. (2-4).
ALK- positive Anaplastic large cell lymphoma is a peripheral T cell lymphoma usually consisting of large lymphoid cells with abundant amphophilic cytoplasm, often horseshoe shaped nuclei, an ALK (anaplastic lymphoma kinase) gene translocation and expression of ALK protein and CD30 (1). Systemic or diffuse anaplastic large cell lymphoma is a non-Hodgkin lymphoma (NHL) of T-cell or null lineage, characterized by proliferation of pleomorphic cells with strongly and uniformly CD30 positivity. Anaplastic large cell lymphoma (ALCL) originates from peripheral T-lymphocytes and is the most common mature T-cell neoplasm in children and adolescents. All in all, these neoplasms are relatively rare among all types of lymphomas. ALCL comprises about 10-20% of all non-Hodgkin lymphomas (NHL) in the above group of patients. (2-4).
Secondary involvement of the adrenals by non-Hodgkin lymphoma is not uncommon and has been reported in up to 25% of patients with advanced disease at autopsy (5). Secondary lymphoma tends to be homogeneous in attenuation with low-level enhancement and show slow washout on delayed images. However, adrenal involvement specifically in ALK- positive anaplastic large cell lymphoma, a subset of NHLs is not documented in the literature.
Secondary involvement of the adrenals by non-Hodgkin lymphoma is not uncommon and has been reported in up to 25% of patients with advanced disease at autopsy (5). Secondary lymphoma tends to be homogeneous in attenuation with low-level enhancement and show slow washout on delayed images. However, adrenal involvement specifically in ALK- positive anaplastic large cell lymphoma, a subset of NHLs is not documented in the literature.
Clinical Profile:
Clinical Profile:
An 18-year-old teenager presented with a feeling of being unwell, fever and weight loss over the past six months. He also had developed a slowly progressive swelling in the left cheek. On examination a few firm, subdermal nodules were noted along the back Fig 1. The patient was anemic (Hb – 6.8gm/dl) and had raised LDH levels.
An 18-year-old teenager presented with a feeling of being unwell, fever and weight loss over the past six months. He also had developed a slowly progressive swelling in the left cheek. On examination a few firm, subdermal nodules were noted along the back Fig 1. The patient was anemic (Hb – 6.8gm/dl) and had raised LDH levels.
Fig. 1 Multiple firm nodules are noted on the patient's back
Radiological findings:
Radiological findings:
Ultrasound examinations of the right cheek swelling, neck region and abdomen were performed. These showed well defined, hypoechoic, vascular, solid lesions in the superficial lobe of left parotid, the infra-parotid region Fig. 2a, Lesions with a similar morphology were seen in the left suprarenal mass Fig. 2b. Hepatosplenomegaly and multiple enlarged lymph nodes were seen along the along left ICA.
Ultrasound examinations of the right cheek swelling, neck region and abdomen were performed. These showed well defined, hypoechoic, vascular, solid lesions in the superficial lobe of left parotid, the infra-parotid region Fig. 2a, Lesions with a similar morphology were seen in the left suprarenal mass Fig. 2b. Hepatosplenomegaly and multiple enlarged lymph nodes were seen along the along left ICA.
CT with IV iodinated contrast showed a heterogenous, well circumscribed lesion with regular borders measuring 9.9x9.1x10.2 cm Fig 3a in the left suprarenal region. The adrenal gland is not seen separately from the lesion. The lesion is slightly heterogenous, secondary to hypodense hypo enhancing areas secondary to necrosis Fig 3b. The lesion has low level enhancement with few areas showing slow washout on delayed images Fig. 3c. There are no calcifications, hemorrhagic foci, or fat attenuation within the lesion. Fat planes with the adjacent structures are maintained. The ipsilateral renal vein was normal.
CT with IV iodinated contrast showed a heterogenous, well circumscribed lesion with regular borders measuring 9.9x9.1x10.2 cm Fig 3a in the left suprarenal region. The adrenal gland is not seen separately from the lesion. The lesion is slightly heterogenous, secondary to hypodense hypo enhancing areas secondary to necrosis Fig 3b. The lesion has low level enhancement with few areas showing slow washout on delayed images Fig. 3c. There are no calcifications, hemorrhagic foci, or fat attenuation within the lesion. Fat planes with the adjacent structures are maintained. The ipsilateral renal vein was normal.
There were multiple, enlarged, heterogeneously enhancing lesions in the parotid and infraparotid region and enlarged lymph nodes in group II,III,IV of left cervical lymph node group. The largest measured 4.1x3.2cm and was located in the infraparotid area Fig 4. Similar heterogeneously enhancing lymph nodes were noted in the precaval, paracaval and aorto-caval - the largest measuring 3.6x2.1cm Fig. 5a,b. There is gross hepatosplenomegaly, the liver measuring 19.2cm in CC axis and splenic length of 18cm. There are multiple enhancing soft tissue density lesions along the anterior and posterior abdominal walls Fig, 6 a,b,c.
There were multiple, enlarged, heterogeneously enhancing lesions in the parotid and infraparotid region and enlarged lymph nodes in group II,III,IV of left cervical lymph node group. The largest measured 4.1x3.2cm and was located in the infraparotid area Fig 4. Similar heterogeneously enhancing lymph nodes were noted in the precaval, paracaval and aorto-caval - the largest measuring 3.6x2.1cm Fig. 5a,b. There is gross hepatosplenomegaly, the liver measuring 19.2cm in CC axis and splenic length of 18cm. There are multiple enhancing soft tissue density lesions along the anterior and posterior abdominal walls Fig, 6 a,b,c.
The low-level enhancement of the adrenal lesion with absence of macroscopic fat and calcification, sparing of surrounding vascular structures, extensive subdermal nodules and gross hepatosplenomegaly favored secondary adrenal lymphoma over ACC (adrenocortical carcinoma), myelolipoma or secondary metastases from a concomitant carcinoma elsewhere. This further was enforced by the similar morphologic characteristics of adrenal and infraparotid, parotid lesions on ultrasound and CT imaging. Further metabolic workup for endocrine axis disturbances was done in view of adrenal lesion, all of which were within normal limits.
The low-level enhancement of the adrenal lesion with absence of macroscopic fat and calcification, sparing of surrounding vascular structures, extensive subdermal nodules and gross hepatosplenomegaly favored secondary adrenal lymphoma over ACC (adrenocortical carcinoma), myelolipoma or secondary metastases from a concomitant carcinoma elsewhere. This further was enforced by the similar morphologic characteristics of adrenal and infraparotid, parotid lesions on ultrasound and CT imaging. Further metabolic workup for endocrine axis disturbances was done in view of adrenal lesion, all of which were within normal limits.
Fig. 2 A & B (A): Left infraparotid lesion, a heterogeneously hypoechoic solid lesion is noted on grayscale imaging. On color doppler there was moderate vascularity in the lesion. B.
A lesion with a similar morphology is noted in the left suprarenal fossa.
Fig. 3 A (A): Reconstructed coronal image of contrast enhanced CT shows well defined heterogenous mildly enhancing left suprarenal lesion with few areas of necrosis within.
Fig 3 b, c, d
CT he left adrenal mass shows mild enhancement on contrast enhanced CT and slow washout on delayed phase.
Fig 4 Similar soft tissue enhancing lesion is seen in the left infraparotid area.
Fig 5 A , B : Few enhancing enlarged retroperitoneal lymph nodes are seen. Fig 5(A) in precaval region and Fig 5(B) along right common iliac vein.
Fig 6 6(A) and (B): Few subdermal deposits are noted along the posterior abdominal wall.
Radiological diagnosis:
Radiological diagnosis:
Non-Hodgkin lymphoma A sonography guided core biopsy of the infraparotid lesion was done.
Non-Hodgkin lymphoma A sonography guided core biopsy of the infraparotid lesion was done.
Pathological diagnosis:
Pathological diagnosis:
Final immunohistopathological analysis showed atypical large cells positive for CD30 and ALK 1 (cytoplasmic positivity), while negative for AE1/AE3, CD3 and CD20. These findings are suggestive ALK positive large cell lymphoma (ALCL).
Final immunohistopathological analysis showed atypical large cells positive for CD30 and ALK 1 (cytoplasmic positivity), while negative for AE1/AE3, CD3 and CD20. These findings are suggestive ALK positive large cell lymphoma (ALCL).
Pathological diagnosis:
Pathological diagnosis:
Final immunohistopathological analysis showed atypical large cells positive for CD30 and ALK 1 (cytoplasmic positivity), while negative for AE1/AE3, CD3 and CD20. These findings are suggestive ALK positive large cell lymphoma (ALCL).
Final immunohistopathological analysis showed atypical large cells positive for CD30 and ALK 1 (cytoplasmic positivity), while negative for AE1/AE3, CD3 and CD20. These findings are suggestive ALK positive large cell lymphoma (ALCL).
Treatment
Treatment
Chemotherapy was initiated following the diagnosis.
Chemotherapy was initiated following the diagnosis.
Discussion:
Discussion:
ALK- positive anaplastic large cell lymphoma is a peripheral T cell lymphoma usually consisting of large lymphoid cells with abundant amphophilic cytoplasm, often horseshoe shaped nuclei, an ALK (anaplastic lymphoma kinase) gene translocation and expression of ALK protein and CD30.
ALK- positive anaplastic large cell lymphoma is a peripheral T cell lymphoma usually consisting of large lymphoid cells with abundant amphophilic cytoplasm, often horseshoe shaped nuclei, an ALK (anaplastic lymphoma kinase) gene translocation and expression of ALK protein and CD30.
Oncogenic translocations result in constitutive activation of the ALK tyrosine kinase. Resulting fusion proteins are shown to be involved in different downstream signalling pathways including Ras/ERK, PI3K/Akt and JAK/STAT. (5)
Oncogenic translocations result in constitutive activation of the ALK tyrosine kinase. Resulting fusion proteins are shown to be involved in different downstream signalling pathways including Ras/ERK, PI3K/Akt and JAK/STAT. (5)
ALK+ ALCL mostly occurs in the first 3 decades of life with male predominance being particularly striking in the second and third decades of life (male/female ratio 6.5).(7) This lymphoma frequently presents as an aggressive stage III to IV disease, usually associated with systemic symptoms (75%), especially high fever. (8)In a large study, the frequency of extra nodal sites of lymphoma involvement was as follows: skin 21%, bone (solitary or multiple lesions) 17% (Figure 10), soft tissues 17% (Figure 10), lung 11%, and liver 8%, with involvement of the gut and central nervous system (CNS) being a rare event. Adrenal lesions have not been documented, likely due to the relative rarity of involvement.
ALK+ ALCL mostly occurs in the first 3 decades of life with male predominance being particularly striking in the second and third decades of life (male/female ratio 6.5).(7) This lymphoma frequently presents as an aggressive stage III to IV disease, usually associated with systemic symptoms (75%), especially high fever. (8)In a large study, the frequency of extra nodal sites of lymphoma involvement was as follows: skin 21%, bone (solitary or multiple lesions) 17% (Figure 10), soft tissues 17% (Figure 10), lung 11%, and liver 8%, with involvement of the gut and central nervous system (CNS) being a rare event. Adrenal lesions have not been documented, likely due to the relative rarity of involvement.
The majority (50–70%) of patients present with stage III–IV advanced disease with peripheral, including mediastinal, and/or abdominal lymphadenopathy.5,10-14 Patients often have B symptoms (54–75%),5,9,10,12,13,15, and extra nodal involvement is frequently observed (approximately 60% of cases). In a report from the International Peripheral T cell Lymphoma (IPTL) project, a retrospective study in which the clinical features of 87 patients with ALK-positive ALCL were analyzed, the incidence of abnormal laboratory results were as follows: lactate dehydrogenase (LDH) elevation (37%), anemia (27%), and thrombocytopenia (10%). (9)
The majority (50–70%) of patients present with stage III–IV advanced disease with peripheral, including mediastinal, and/or abdominal lymphadenopathy.5,10-14 Patients often have B symptoms (54–75%),5,9,10,12,13,15, and extra nodal involvement is frequently observed (approximately 60% of cases). In a report from the International Peripheral T cell Lymphoma (IPTL) project, a retrospective study in which the clinical features of 87 patients with ALK-positive ALCL were analyzed, the incidence of abnormal laboratory results were as follows: lactate dehydrogenase (LDH) elevation (37%), anemia (27%), and thrombocytopenia (10%). (9)
Imaging characteristics:
Imaging characteristics:
The imaging pattern of adrenal affection of lymphomas are non-specific. If a lesion does not contain visible regions of fat, as in myelolipoma, or represent an ACA at adrenal protocol CT or chemical shift MR imaging, then lymphoma remains a possibility, along with other benign and malignant conditions., Adrenal hyperplasia should be considered when there is diffuse gland involvement. The presence of aggressive vascular invasion would suggest ACC rather than lymphoma, which tends to surround vessels rather than displace them. In secondary adrenal lymphoma, the adrenals may appear normal, diffusely enlarge while maintaining a normal morphology, or demonstrate solitary or multiple masses. Extensive retroperitoneal disease may engulf the adrenals. Secondary lymphoma tends to be homogeneous in attenuation with low-level enhancement and slow washout on delayed images. The presence of calcifications in a large adrenal lesion that has not been treated would suggest ACC over lymphoma. (10.)
The imaging pattern of adrenal affection of lymphomas are non-specific. If a lesion does not contain visible regions of fat, as in myelolipoma, or represent an ACA at adrenal protocol CT or chemical shift MR imaging, then lymphoma remains a possibility, along with other benign and malignant conditions., Adrenal hyperplasia should be considered when there is diffuse gland involvement. The presence of aggressive vascular invasion would suggest ACC rather than lymphoma, which tends to surround vessels rather than displace them. In secondary adrenal lymphoma, the adrenals may appear normal, diffusely enlarge while maintaining a normal morphology, or demonstrate solitary or multiple masses. Extensive retroperitoneal disease may engulf the adrenals. Secondary lymphoma tends to be homogeneous in attenuation with low-level enhancement and slow washout on delayed images. The presence of calcifications in a large adrenal lesion that has not been treated would suggest ACC over lymphoma. (10.)
No clear correlation has been established between the distribution of the lymphomatous process and the presence of an adrenal mass. This serves to corroborate the near-random manner in which non-Hodgkin lymphoma spreads. The presence of an adrenal mass in a patient with non- Hodgkin lymphoma should be regarded as evidence of extra nodal involvement by that lymphoma and should cause no diagnostic problem. Only if the adrenal mass differs in its CT appearance from tumor elsewhere in the patient, or if it fails to respond to therapy that proves effective for tumor at other sites, should an alternative diagnosis be suspected. (11) In the setting of known lymphoma, the diagnosis may be presumed, with imaging follow-up to assess for treatment response.
No clear correlation has been established between the distribution of the lymphomatous process and the presence of an adrenal mass. This serves to corroborate the near-random manner in which non-Hodgkin lymphoma spreads. The presence of an adrenal mass in a patient with non- Hodgkin lymphoma should be regarded as evidence of extra nodal involvement by that lymphoma and should cause no diagnostic problem. Only if the adrenal mass differs in its CT appearance from tumor elsewhere in the patient, or if it fails to respond to therapy that proves effective for tumor at other sites, should an alternative diagnosis be suspected. (11) In the setting of known lymphoma, the diagnosis may be presumed, with imaging follow-up to assess for treatment response.
At MR imaging, primary and secondary lymphomas are hypointense to isointense on T1-weighted images and hyperintense on T2- weighted images when compared with liver (12.16). Mild to moderate enhancement is commonly seen (13).
At MR imaging, primary and secondary lymphomas are hypointense to isointense on T1-weighted images and hyperintense on T2- weighted images when compared with liver (12.16). Mild to moderate enhancement is commonly seen (13).
Unlike CT and MRI, 18F-FDG PET/ CT is based on increased glucose metabolism in malignant lesions. PET/CT show intense FDG avid adrenal masses (14). The degree of FDG avidity in adrenal lymphoma tends to parallel that in other involved areas. However, certain subtypes of lymphoma (e.g. marginal zone and peripheral T-cell) and low-grade lymphomas may not show reliable FDG uptake (15).
Unlike CT and MRI, 18F-FDG PET/ CT is based on increased glucose metabolism in malignant lesions. PET/CT show intense FDG avid adrenal masses (14). The degree of FDG avidity in adrenal lymphoma tends to parallel that in other involved areas. However, certain subtypes of lymphoma (e.g. marginal zone and peripheral T-cell) and low-grade lymphomas may not show reliable FDG uptake (15).
Adrenal insufficiency seems to be unusual in adrenal lymphoma either because only one side is involved or because sufficient normal tissue remains to sustain adrenal function.
Adrenal insufficiency seems to be unusual in adrenal lymphoma either because only one side is involved or because sufficient normal tissue remains to sustain adrenal function.
In a retrospective study,4% of patients with NHL showed evidence of adrenal involvement at some time during the course of their disease. This frequency of adrenal involvement is similar to that reported for other extra-nodal abdominal sites. The response of these adrenal masses to chemotherapy in a manner similar to the response of coincidental masses elsewhere reinforces the impression that the adrenal pathology was indeed due to the non-Hodgkin lymphoma.
In a retrospective study,4% of patients with NHL showed evidence of adrenal involvement at some time during the course of their disease. This frequency of adrenal involvement is similar to that reported for other extra-nodal abdominal sites. The response of these adrenal masses to chemotherapy in a manner similar to the response of coincidental masses elsewhere reinforces the impression that the adrenal pathology was indeed due to the non-Hodgkin lymphoma.
ALK+ ALCL has the best prognosis among T-cell lymphomas. First-line doxorubicin-based chemotherapy is associated with a 90% ORR, and a 5-year OS of 70%. High-dose chemotherapy and ASCT lead to favorable results in patients in first remission, but superiority to standard chemotherapy is unproven. The development of novel therapies targeting CD30 and ALK appear promising. (16)
ALK+ ALCL has the best prognosis among T-cell lymphomas. First-line doxorubicin-based chemotherapy is associated with a 90% ORR, and a 5-year OS of 70%. High-dose chemotherapy and ASCT lead to favorable results in patients in first remission, but superiority to standard chemotherapy is unproven. The development of novel therapies targeting CD30 and ALK appear promising. (16)
Conclusion:
Conclusion:
The present case is an uncommon case of disseminated ALK-positive ALCL with adrenal gland involvement in a young adult. The low-level enhancement of the adrenal lesion with absence of macroscopic fat and calcification, sparing of surrounding vascular structures, extensive subdermal nodules and gross hepatosplenomegaly favored secondary adrenal lymphoma over ACC (adrenocortical carcinoma), myelolipoma or secondary metastases from a concomitant carcinoma elsewhere. This further was enforced by the similar morphologic characteristics of adrenal and infraparotid, parotid lesions on ultrasound and CT imaging.
The present case is an uncommon case of disseminated ALK-positive ALCL with adrenal gland involvement in a young adult. The low-level enhancement of the adrenal lesion with absence of macroscopic fat and calcification, sparing of surrounding vascular structures, extensive subdermal nodules and gross hepatosplenomegaly favored secondary adrenal lymphoma over ACC (adrenocortical carcinoma), myelolipoma or secondary metastases from a concomitant carcinoma elsewhere. This further was enforced by the similar morphologic characteristics of adrenal and infraparotid, parotid lesions on ultrasound and CT imaging.
References:
References:
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