Annals of Oncology Advance Access originally published online on October 16, 2006
Annals of Oncology 2007 18(1):122-128; doi:10.1093/annonc/mdl349
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© 2006 European Society for Medical Oncology
hematologic malignancies |
Clinicopathological features of pyothorax-associated lymphoma; a retrospective survey involving 98 patients
1 Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya
2 Department of Pathology, Toranomon Hospital, Tokyo
3 Division of Exploratory Research, the Institute of Medical Science, the University of Tokyo, Tokyo
4 Department of Pathology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo
5 Division of Molecular Medicine, Aichi Cancer Center, Nagoya
6 Division of Epidemiology and Prevention, Aichi Cancer Center Research Institute, Nagoya
7 Division of Genetic Therapeutics, Center for Molecular Medicine, Jichi Medical School, Tochigi
8 Department of Transfusion Medicine, Metropolitan Fuchu Hospital, Tokyo
9 First Department of Internal Medicine, Nihon University School of Medicine, Tokyo
10 Department of Radiology, Toyama Prefectural Central Hospital, Toyama
11 Department of Chemotherapy, Tokyo Metropolitan Komagome Hospital, Tokyo
12 Hematology Division, National Cancer Center Hospital, Tokyo
13 Division of Respiratory Diseases, Toranomon Hospital, Tokyo
14 Division of Hematology, Japanese Red Cross Nagoya First Hospital, Nagoya
15 Third Department of Internal Medicine, Faculty of Medicine, University of Tokyo, Tokyo
16 Department of Internal Medicine and Molecular Science, Nagoya City University School of Medicine, Nagoya
17 Department of Clinical Pathology, Nagoya University Graduate School of Medicine, Nagoya, Japan
* Correspondence to: Dr M. Kami, Division of Exploratory Research, the Institute of Medical Science, University of Tokyo, 4-6-1 Shirokanedai, Minato-ku, Tokyo 108-8639, Japan. Tel: +81-3-6409-2068; Fax: +81-3-6409-2069: E-mail: kami-tky{at}umin.ac.jp
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Abstract |
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To investigate clinicopathological features of pyothorax-associated lymphoma (PAL), we examined medical records of 98 patients (88 males and 10 females) with PAL at a median age of 70 years (range 51–86). Seventy-nine patients had a history of artificial pneumothorax. Median interval between diagnosis and artificial pneumothorax was 43 years (range 19–64). At diagnosis, performance status (PS) was 0–1 (n = 56) and 2–4 (n = 42). Clinical stages were I (n = 42), II (n = 26), III (n = 8) and IV (n = 22). Pathological diagnosis comprised diffuse large-B-cell (n = 78) and peripheral T-cell lymphoma (n = 1). Seventeen were treated supportively. The other 81 received aggressive treatments; chemotherapy (n = 52), radiotherapy (n = 7), surgery (n = 4) and combination (n = 18). Five-year overall survival (OS) was 0.35 (95% confidence interval, 24% to 45%). Causes of deaths were PAL (n = 39), respiratory failure (n = 13) and others (n = 12). Multivariate analysis identified prognostic factors for OS; lactate dehydrogenase levels [hazard ratio (HR) = 2.36; P = 0.013], sex (female versus male) (HR = 0.15; P = 0.01), PS (2–4 versus 0–1) (HR = 2.20; P = 0.02), clinical stages (III/IV versus I/II) (HR = 1.95; P = 0.037) and chemotherapy (HR = 0.31; P = 0.01). Most patients with PAL are elderly and have comorbidities, while some of them achieve durable remission with appropriate treatments. These findings prompt us to establish an optimal treatment strategy on the basis of risk stratification of individual patients.
Key words: artificial pneumothorax, diffuse large B-cell lymphoma, Epstein–Barr virus, malignant lymphoma, tuberculosis
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introduction |
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TopAbstractintroductionpatients and methodsresultsdiscussionappendixAcknowledgementsReferences |
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Pyothorax-associated lymphoma (PAL) is a lymphoproliferative disorder developing in the pleural cavity after a long-standing history of pyothorax. While the pathogenesis, clinical features and optimal treatment have not been clarified, PAL represents an entity distinct from other malignant lymphomas [1]. PAL usually develops in patients who have undergone artificial pneumothorax for the treatment of pulmonary tuberculosis, and the interval between the operation and development of PAL has been reported to be 22–55 years [1–7]. Most studies on PAL are reported from Japan, but occasionally from other Asian [8] and Western countries [9] in the recent literature. Artificial pneumothorax, as a form of surgical treatment of lung tuberculosis, had been more widely carried out in Japan than in the Western countries, especially in the 1930s to 1950s [10]. Artificial pneumothorax is the most significant risk factor for development of PAL [10]. Approximately 2% of patients with chronic pyothorax develop PAL [7]. In the majority of these patients, the lymphoma cells are classified as large atypical B cells, and they express latent gene products of Epstein–Barr virus (EBV) [11, 12].
Optimal management of PAL is unclear. In Japan, 
70% of patients with PAL receive chemotherapy and/or radiotherapy [1]. Recent studies showed that PAL is responsive to chemotherapy [6] and radiotherapy, but the overall prognosis is poor, with a 5-year survival of 21.6% [6]. Some case series indicated that surgical interventions including open-window thoracostomy and pleuropneumonectomy are beneficial for the treatment of PAL [1]; however, their studies are too small to make a definite conclusion. Since most patients with PAL are elderly and/or have comorbidities, invasive approaches are not feasible options in these patients. Treatment strategy of PAL must be established on the basis of the risk stratification of individual patients. We reviewed 98 cases of patients with PAL to investigate its clinicopathological features, treatment outcomes and prognostic factors.
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patients and methods |
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patient selection and clinical records
We collected data from a total of 139 cases of PAL from 88 collaborating institutions. Clinical, pathological, immunophenotypic and karyotypic data were obtained from patients' records, autopsy request forms and pathological reports in 98 patients. Four cases were reported previously in the nationwide retrospective analysis in Japan [2, 6]. All the patients were diagnosed from November 1980 to May 2001. Performance status (PS) was evaluated by using Eastern Cooperative Oncology Group (ECOG) PS [13]. International Prognostic Index was evaluated as previously described [14].
Histological diagnosis was done on the basis of institutional diagnosis. Discrepancies in nomenclature among centers were resolved according to the synonyms in the World Health Organisation classification [15].
diagnostic criteria of PAL
PAL was defined as lymphoma developing in the pyothorax with or without involvement of regional lymph nodes or other visceral tissues [6]. Diagnosis of PAL was made by pathological examination of biopsy specimens obtained from the lesion in the pleural cavity or autopsy. Diagnosis of PAL was not established in patients without lesions in the pleural cavity or those without a history of pyothorax. Clinical stages were evaluated according to the proposed criteria [16].
end points and statistical analysis
The end points of this study are to (i) describe clinicopathological features of PAL, (ii) clarify its prognostic factors and (iii) investigate its optimal treatment. The probability of survival was calculated as a function of time with the Kaplan–Meier method. The estimated survival was calculated as of 31 July 2001. A log-rank test was applied to assess the impact by the factor of interest when appropriate. Uni- and multivariate Cox proportional hazard models were applied to assess the impact of potential prognostic factors. Multivariate model was built with forward/backward stepwise method using threshold P value for removal and adding in the model as 0.20 and 0.10, respectively. We applied P value <0.05 as statistical significance. All the analyses were conducted by STATA version 9.2 (STATA Corp., College Station, TX).
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results |
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patients' characteristics
Patients' characteristics at the diagnosis of PAL are shown in Table 1. There were 88 males and 10 females, and their median age was 70 years (range 51–86). Seventy-nine patients (81%) had a history of artificial pneumothorax, and median interval between diagnosis of PAL and artificial pneumothorax was 43 years (range 19–64). At the diagnosis of PAL, PS was 0–1 (n = 56) and 2–4 (n = 42), and 49 patients (50%) had B symptoms. Clinical stages were I (n = 42), II (n = 26), III (n = 8) and IV (n = 22).
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pathological examination
In situ hybridization using a probe for EBV-encoded RNA-1 demonstrated the presence of the EBV genome in the nucleus of tumor cells in 28 of 29 (88%) patients. Immunohistochemical studies revealed that 12 of 14 (86%) and 11 of 17 (65%) patients were positive for Epstein–Barr virus nuclear antigen (EBNA)-2 and latent membrane protein (LMP)-1, respectively. Immunohistochemical analysis for human herpes virus (HHV)-8 detection in lymphoma cells was not conducted.
Information on pathological diagnosis was available in 79 patients. The diagnosis included diffuse large B-cell lymphoma (n = 78) and peripheral T-cell lymphoma (n = 1). Immunohistochemical characteristics of lymphoma cells are shown in Table 1. Information on cytogenetic analysis was obtained in seven patients. Two patients had a normal karyotype. One patient had the abnormality of dicentric (15;18)(p11:p11). The remaining four patients had a complex karyotype, including 56–64, XX, –X, add(1)(q11), add(4)(q31) (n=1), add(3)(p11), –18, +mar (n=1) and hyperdiploid with abnormality of 3p, 8q, 15p (n=1). The information was not available in one patient.
treatment and outcomes
Seventeen patients (17%) were treated supportively, and the other 81 patients (83%) received aggressive treatments (Table 2). Response rates to chemotherapy, radiotherapy and chemoradiotherapy were 56%, 71% and 83%, respectively. Since assessable lesions were completely removed by surgery, response was not assessable in the remaining 10 patients who received it. Clinical characteristics and outcomes according to clinical stages are shown in Table 2.
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Sixty-four patients died during their clinical courses. Their causes of deaths included PAL (n = 39), respiratory failure (n = 13) and others (n = 12) (Table 2). Four patients died without recurrence of PAL. Autopsy was conducted in 22 patients. Either ante-mortem or post-mortem examination revealed multiorgan involvement of PAL in 69 patients (70%). These organs included lymph nodes (n = 32), liver (n = 12), bone (n = 9), bone marrow (n = 8), contralateral lung (n = 13), gastrointestinal tract (n = 9), central nervous system (n = 8), spleen (n = 6), diaphragm (n = 4), pancreas (n = 5), skin (n = 8), kidney (n = 5), heart (n = 3), bladder (n = 2), prostate (n = 2) and testis (n = 2).
Median follow-up of the surviving patients was 33 months (range 1–241 months). The 5-year overall survival (OS) rate was 0.35 [95% confidence interval (CI) 0.24–0.45] (Figure 1). The 5-year OS rate was 0.47 (95% CI 0.30–0.63), 0.35 (95% CI 0.16–0.54) and 0.15 (95% CI 0.04–0.33) in patients with stages I, II and I–IV disease, respectively (Figure 2). Of the 41 patients with stage I disease, four received surgery alone as a primary treatment. Two patients died at 8 and 47 months after the diagnosis of PAL due to progression of underlying disease and respiratory failure, respectively. The remaining two patients are alive 32 and 62 months after the diagnosis of PAL.
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prognostic factors of PAL
Prognostic factors of PAL are shown in Table 3. Multivariate analysis identified several prognostic factors for OS; lactate dehydrogenase (LDH) levels [hazard ratio (HR) = 2.36; P = 0.013], sex (female versus male) (HR = 0.15; P = 0.01), PS (2–4 versus 0–1) (HR = 2.20; P = 0.02), clinical stages (III/IV versus I/II) (HR = 1.95; P = 0.037) and chemotherapy (HR = 0.31; P = 0.01).
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discussion |
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Clinical features of PAL shown in the present study are comparable to previous reports [2, 6, 7, 17]. PAL develops in elderly patients with a history of artificial pneumothorax, and median interval between artificial pneumothorax and the diagnosis of PAL was 43 years (range 19–64). Approximately two thirds of patients had localized diseases, whereas the PS was poor even in patients with early-stage disease. The present nationwide study showed that the ECOG PS was
3 in 43% of the patients with PAL, while the patients with good general conditions were reported in a previous small-sized case report from Japan [18]. Underlying chronic pyothorax or respiratory failure, which is probably associated with the poor PS, can be an obstacle to the treatment of PAL. Male predominance has been demonstrated in reports on PAL, and most researchers discussed that it is attributable to the male dominance of tuberculosis [2, 6, 7, 17]. The male : female ratio in the present study and in the previous study from Japan [19] was 9 : 1 and 12.3 : 1, respectively. While these are not comparable, these are remarkably higher than the ratio of 2 : 1 in the Japanese patients with tuberculosis [20]. It is reasonable to assume that genetical and/or environmental factors other than tuberculosis might be involved in the male dominance of PAL and that these might be associated with the pathogenesis of PAL. In consideration of future clinical significance of PAL, it should be noted that 20% of the patients have not received artificial pneumothorax in the present study. Artificial pneumothorax is now rarely conducted in Japan; however, the present study indicates the possibility that PAL can occur in patients with structural lung diseases, genetic abnormalities, and disorders of innate or acquired immunity [21]. PAL remains an important clinical entity, and further investigations are awaited on PAL without a history of artificial pneumothorax. Immunohistochemical analyses for HHV-8 detection in lymphoma cells were required in those patients to exclude the possibility of HHV-8-associated primary effusion lymphoma, which has been reported in elderly patients without immune deficiency [22].
The present study showed that the clinical stage of PAL is an important variable in the therapeutic decision making for PAL. Advanced PAL has a poor prognosis; the 5-year survival rate was 15% in patients with PAL at stage 3–4. Approximately 30% of these patients were treated with supportive measures due to advanced ages and/or comorbidities, while the remaining 70% of the patients received aggressive treatments. These findings indicate that it is difficult to control advanced PAL with the current therapeutic procedures on the basis of combination chemotherapy with cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP). Considering that no patients were given either rituximab or ibritumomab in the present study, clinical significance of these molecular agents warrant further investigation.
In contrast, some patients with PAL at an early stage achieved durable remission in the present study. PAL at an early stage can be cured with the current therapeutic measures. Development of PAL is associated with chronic inflammation, and these situations are similar with malignant lymphoma of mucosa-associated lymphoid tissue and that of thyroid gland, in which Helicobacter pylori-induced gastritis and Hashimoto's thyroiditis contribute to their pathogenesis [23, 24]. Surgery generally plays a limited role in the treatment of malignant lymphoma, while surgical resections of lymphoma lesions are frequently curative in these lymphomas [25–27]. Four patients with PAL at stage 1–2 were treated with surgery alone in the present study, and two achieved durable remission. Surgical resection might be curative for early-stage PAL. Further studies are warranted to investigate its role in the treatment of PAL. On the other hand, one patient died of recurrence of PAL, and distant lesions of PAL can be overlooked using the current diagnostic procedures. Since PAL occasionally involves the extra nodal organs [28], precise evaluation of clinical stage is essential to establish optimal treatments for PAL. Novel diagnostic modalities, such as magnetic resonance imaging and positron emission tomography, may be useful for making an accurate staging of PAL [29].
Immunohistochemical examination of PAL cells in the present study has shown the same expression pattern as reported previously [1, 6, 7, 30–32]. PAL cells expressed some EBV-associated antigens; EBNA-2 and LMP-1 in 12 of 14 and 11 of 17 patients, respectively. These antigens are targets of the cytotoxic T lymphocytes [33], and the expression pattern of EBV-associated antigens in PAL is categorized as latency III, which is same as the pattern of malignant lymphomas developing in immunocompromised patients. These findings raise the possibility of underlying immune defects in PAL; however, a majority of the patients with PAL are immunocompetent. It remains unknown how PAL evades the immune system in immunocompetent patients, but it is to be noted that PAL develops in the lung abscess and that it sometimes stays there without any nodal involvement. In the present study, 66 of the 98 patients with PAL had not presented nodal involvement through their clinical courses. Since the immune system cannot work well in the space of abscess [30], PAL may be able to survive in the lung abscess even in immunocompetent patients. Nodal involvement rarely occurs until progression of PAL, and some genetic events such as loss of tumor suppressor genes may be required for the dissemination of PAL. Clinicopathological studies using molecular [34, 35] and immunological techniques [36] are warranted to clarify the mechanism of immune escape and progression of PAL.
Identification of prognostic factors of PAL is important to establish an optimal treatment strategy, considering that some patients with PAL at early stage can be cured with adequate treatments and that approximately two thirds of the patients were at stage 1–2 when the diagnosis of PAL was established. The present study has demonstrated that sex is significantly associated with survivals as well as conventional prognostic factors including serum levels of LDH, clinical stage and PS [37]. Interestingly, none of the 10 female patients died of disease progression (data not shown). The prognosis is more favorable in females than in males. These observations will provide an important clue to investigate the pathogenesis of PAL. Sex hormones per se might play a role in the development and progression of PAL. Alternatively, some factors associated with sex might be involved in the lymphomagenesis and progression of PAL. Previous epidemiological studies have identified several risk factors of malignant lymphoma, and some of them are associated with sex. These included pregnancy [38], smoking history [39] and alcohol consumption [40]. Further studies are warranted to investigate the association between sex and PAL.
While the present study provided novel information on PAL, it has some limitations to be discussed. Firstly, this is a retrospective study, involving a small number of patients. It might have been influenced by unrecognized bias. Secondly, the present study provided little information on morphological, immunohistochemical, karyotypic and genetic findings of PAL. More detailed information on these findings has to be investigated. The more detailed macroscopic findings, such as size of lesions and the depth of the invasion of pleura, are also needed. Thirdly, clinical features of PAL, which is not associated with pneumothorax, are not clarified, while these kinds of PAL may become a significant problem in the future. Fourthly, information of the type and the degree of comorbidities is limited in the present study although these comorbidities have an impact on response rate and survival in the elderly patients. Lastly, optimal treatments for PAL have not been established. These findings prompt us to conduct further large-scale prospective studies.
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This study was conducted at the following institutions under the auspices of the following investigators in Japan: M. Kami and M. Kawabata (Toranomon Hospital, Tokyo); Y. Tanaka and A. Yamazaki (Tokyo University Hospital, Tokyo); K. Mori (Juntendo University Hospital, Tokyo); M. Mori (Tokyo Metropolitan Geriatric Hospital, Tokyo); S. Sunaga (Hitachi General Hospital, Hitachi); J. Kojima and S. Komastumoto (Dokkyo Medical University School of Medicine, Tochigi and Ashikaga Red Cross Hospital, Ashikaga); S. Miyata (Toyama Prefectural Central Hospital, Toyama); T. Hashizume (National Hospital Organization Kanagawa Hospital, Hatano); M. Fukase (Shonai Hospital, Tsuruoka); S. Okamoto (Keio University School of Medicine, Tokyo); Y. Irie (Saga Prefectural Hospital Koseikan, Saga); T. Miki and Y. Hashimoto (Himeji Brain and Heart Center, Himeji); K. Nakayama (Nihon University School of Medicine, Tokyo); Y. Atsuta and T. Nishida (Nagoya First Red Cross Hospital); A. Hirasawa (Yokohama Rosai Hospital, Yokohama); A. Taguchi (Yokohama City University Hospital, Yokohama); M. Yagita (Kitano Hospital, Osaka); T. Kumagai and Y. Adachi (NTT Kanto Medical Center, Tokyo); K. Tanaka (Kurume University Hospital, Kurume); M. Takagawa (Ishinomaki Red Cross Hospital, Ishinomaki); H. Yanai (Hiroshima City Hospital, Hiroshima); S. Hara (Kurashiki Daiichi Hospital, Kurashiki); S. Taniguchi (Hamanomachi Hospital, Fukuoka); J. Suzumiya (Fukuoka University Hospital, Fukuoka); T. Ishibashi (Shizuoka Hospital, Shizuoka); H. Ishihara (Yamanashi University Hospital, Yamanashi); S. Fukuda (Okayama Medical Center, Okayama); M. Kurosawa (Sapporo Kosei Hospital, Sapporo); A. Wakita (Nagoya City University Hospital, Nagoya); H. Saito (Nagano Red Cross Hospital, Nagano); K. Tsukazaki (Nagasaki University Hospital, Nagasaki); F. Nagamura (Institute of Medical Science, University of Tokyo, Tokyo); K. Suga (Saga Medical University Hospital, Saga); Y. Hasegawa (Tsukuba University Hospital, Tsukuba); H. Mizuno (Chukyo Hospital, Nagoya); A. Oyama (Aichi Prefectural Hospital, Okazaki); R. Suzuki (Aichi Cancer Center Hospital, Nagoya); T. Kato (Higashi Nagoya Hospital, Nagoya); M. Kajita (Hekinan Municipal Hospital, Hekinan); T. Kataoka (Nagoya Memorial Hospital, Nagoya); Y. Morishita (JA Aichi Showa Hospital, Konan); Y. Hamano (Showa University Hospital, Tokyo); H. Ikeda (Sapporo City General Hospital, Sapporo); T. Miyoshi (Kitakyushu Municipal Medical Center, Kitakyushu); S. Ozaki (Tokushima University Hospital, Tokushima); K. Tobinai, A. Hori and Y. Matsuno (National Cancer Center Hospital, Tokyo); M. Daibata (Kochi Medical School Hospital, Kochi); S. Tamaki (Yamada Red Cross Hospital, Ise); Y. Inoue (Japanese Red Cross Medical Center, Tokyo); T. Ishizaka (University of Fukui Hospital, Fukui); T. Miyakuni (Naha Hospital, Naha); T. Takahashi (Kobe City General Hospital, Kobe); T. Izumi (Jichi Medical School Hospital, Shimotsuke); Y. Kashiwayama (Okayama Red Cross Hospital); T. Tananka (Ota Nishinouchi Hospital, Koriyama); A. Sato (Iwate Prefectural Central Hospital, Morioka); K. Kawakami (Suzuka General Hospital, Suzuka); U. Sawada (Nihon University Itabashi Hospital); T. Hotta (Tokai University Hospital, Isehara); M. Tsuyuguchi (Tokushima Municipal Hospital, Tokushima); Y. Tsunoda (Fujita General Hospital, Kunimi); A. Fujita (Showa General Hospital, Tokyo); T. Katagiri (Tokyo Medical University Hospital, Tokyo); H. Okazaki (Sakai Municipal Hospital, Sakai); T. Yoshino and K. Shinagawa (Okayama University, Okayama) and T. Nakaseko (Chiba University Hospital, Chiba).
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Acknowledgements |
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We are grateful to Hisashi Baba (Department of Infectious Diseases, Nagoya University Hospital) and Katsuyuki Aozasa (Department of Pathology, Osaka University Graduate School of Medicine) for their critical reading of the manuscript and for providing us useful discussion. We thank all the staff and resident members of the participating institutions in Japan. A complete list of participating institutions appears in the Appendix. This study was supported by Health and Labour Sciences Research Grants.
Received for publication June 17, 2006. Revision received August 14, 2006. Accepted for publication August 23, 2006.
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References |
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