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Journal of Clinical Oncology, Vol 25, No 27 (September 20), 2007: pp. 4310-4312 © 2007 American Society of Clinical Oncology. DOI: 10.1200/JCO.2007.12.7092
Extranodal Marginal Zone B-Cell Lymphoma of Mucosa-Associated Lymphoid Tissue Type Developing in Gonarthritis DeformansDepartments of Pathology and Orthopaedic Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
Sumiya Orthopaedic Hospital, Wakayama, Japan
Department of Pathology, Osaka University Graduate School of Medicine, Osaka, Japan A 51-year-old woman had been suffering from right knee pain at gait, and was diagnosed as having gonarthritis deformans after roentgenographic examination and laboratory tests in 2005. Gonarthritis deformans is defined as a degenerative disorder of the knee joint that is characterized by an increasing destruction of the joint cartilages. Magnetic resonance imaging taken during follow-up period at an orthopedic clinic revealed the injury of meniscus. Findings suggestive of rheumatoid arthritis (RA), such as morning stiffness, polyarthritis, swelling of hand joints, symmetric swelling of joints, and rheumatoid nodules were never observed. In February 2007, arthroscopy was carried out. Arthrocentesis yielded clear fluid. Synovium in the right suprapatellar pouch showed nodular swelling, mimicking chondromatosis (Fig 1), which was biopsied. Histologic diagnosis was extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT) type. Fibrillation of medial femoral cartilage and injury of lateral meniscus were found. Then, the patient was admitted to Osaka University Hospital 1 year and 6 months after the onset of symptoms. Physical examination revealed neither lymphadenopathy nor hepatosplenomegaly. Laboratory data were within normal limits. The disease was stable with no antitumor treatment at 3 months after the diagnosis of MALT lymphoma. Histologic examination revealed a formation of lymph follicles with germinal center in the synovial membrane (Fig 2). Surrounding almost bare germinal center (Fig 2A; arrow), there was a diffuse proliferation of small lymphoid cells. These proliferative cells in the interfollicular space showed relatively rich cytoplasm in which small nucleus with slight indentation. Plasma cells with Dutcher body were discernible (Fig 2A; inset, arrowhead). Immunoperoxidase procedure with avidin-biotin complex method showed that the proliferating small lymphoid cells were CD20+ (Fig 2B), CD79a+, CD3–, indicating B-cell nature of these cells. DNA was extracted from the paraffin-embedded samples from the knee joint as described previously.1 Semi-nested polymerase chain reaction (PCR) with primer pairs of FR2A or FR3A and LJH for round 1 and FR2A or FR3A and VLJH for round 2 reactions revealed a monoclonal band (Fig 3; lane 1). As controls, PCR was also performed with DNA of B-cell lymphoma cell (Raji; Fig 3, lane 2, monoclonal band for positive control), no template (Fig 3, lane 3, negative control), and DNA from chronic tonsillitis (Fig 3, lane 4, polyclonal bands for positive control). These showed monoclonal band, no band, and smear, respectively.
There has been accumulating evidence linking chronic inflammation and development of lymphomas. Extranodal marginal zone B-cell lymphomas of MALT type are included in this category because they occur in the tissues normally devoid of lymphoid tissue, but are preceded by chronic inflammation that results in formation of MALT. Chronic inflammation in this category could be divided into autoimmune nature such as Sjogren syndrome, RA, and Hashimoto's thyroiditis,2,3 and nonautoimmune nature such as Helicobacter pylori-induced chronic gastritis.4 MALT lymphomas are characterized by a proliferation of small lymphoid cells (centrocyte-like cells) and usually remain localized in the primary site, thus categorized as low-grade lymphoma. Another example is pyothrax-associated lymphoma, which develops in patients with long-standing pyothorax, and is characterized by a proliferation of large lymphoid cells, thus usually shows an aggressive course.5 Irrespective of the nature of the antecedent chronic inflammation, the lymphomas arising in such conditions are exclusively of B-cell type. This patient had a history of gonarthritis deformans not associated with RA. Pathologic examination revealed histologic picture of MALT lymphoma (ie, presence of lymph follicles and diffuse proliferation of small B-cells) and monoclonal nature of these proliferating B-cells, justifying the diagnosis of MALT lymphoma developing in gonarthritis deformans. To our knowledge, this is the first report of MALT lymphoma developing in gonarthritis deformans. Chronic inflammatory stimulation induces lymphoid cell infiltration with formation of lymph follicles, where malignant lymphomas could develop. Twenty cases of malignant lymphomas developing in synovial membrane mostly of knee joint have been reported to date6-12: preceding diseases for lymphomas include RA receiving methotrexate medication,6 HIV infection,7 and receiving immunosuppressants after renal transplantation.8 All of these antecedent diseases indicate the presence of underlying immunodeficient condition in hosts. Lymphoma development in patients with ankylosing spondylitis9 and a case of metallic implant-associated lymphoma in the right knee were also reported.13 Lymphomas in these patients were reported to be diffuse large B-cell lymphoma. Lymphoma development in patients with gonarthritis deformans was reported, mostly in patients receiving joint arthroplasty.13,14 Malignant lymphoma in a patient with gonarthritis deformans who did not receive arthroplasty was also reported.10 This patient had a 17-year history of arthritis, and the histology of lymphoma was diffuse large B-cell lymphoma. Duration of arthritis until the histologic diagnosis was 17 years in the reported case10 and only 18 months in this case. It is well-known that MALT lymphoma occasionally shows a histologic transformation into diffuse large B-cell lymphoma. Histologic transformation might occur in the reported case10 during a long course. Joints, especially knee joint, are added to candidate site for development of MALT lymphoma. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author(s) indicated no potential conflicts of interest.
ACKNOWLEDGMENTS Supported in part by Grants No. 18590329 and 19790258 from the Ministry of Education, Culture, Sports, Science and Technology, Japan. REFERENCES 1. Greer CE, Wheeler CM, Manos MM: PCR amplification from paraffin-embedded tissues: Samples preparation and the effects of fixation, in Dieffenbach CW, Dveksler GS (eds): PCR Primer. New York, Cold Spring Harbor Laboratory Press, 1995, pp 99-112 2. Kasan SS, Thomas TL, Moutsopoulous HM, et al: Increased risk in sicca syndrome. Ann Intern Med 89:888-892, 1998 3. Kato I, Tajima K, Suchi T, et al: Chronic thyroiditis as a risk factor of B-cell lymphoma in the thyroid gland. Jpn J Cancer Res 76:1085-1090, 1985 4. Isaacson PG, Spencer J: Malignant lymphoma of mucosa-associated lymphoid tissue. Histopathology 11:445-462, 1987[Medline] 5. Aozasa K, Nakatsuka S, Takakuwa T: Pyothorax-associated lymphoma –a lymphoma developing in chronic inflammation. Adv Anat Pathol 12:324-331, 2005[CrossRef][Medline] 6. Chim CS, Pang YY, Ooi GC, et al: EBV-associated synovial lymphoma in a chronically inflamed joint in rheumatoid arthritis receiving prolonged methotrexate treatment. Haematologica 91: ECR31, 2006[Medline] 7. Peeva E, Davidson A, Keiser HD: Synovial non-Hodgkin's lymphoma in a human immunodeficiency virus infected patient. J Rheumatol 26:696-698, 1999[Medline] 8. Pineda R, Wyard L, Tietjen R, et al: Posttransplantation lymphoproliferative disorder in the knee. Clin Orthop Relat Res 350:195-200, 1998[Medline] 9. Khan SY, Hutchinson DG: Primary synovial non-Hodgkin's lymphoma in association with ankylosing spondylitis. Rheumatology 43:391, 2004 10. Ogose A, Kawashima H, Hotta T, et al: Conditions suggesting lymphoma: Case 3. Primary synovial lymphoma with osteoclast-like giant cells presenting as a tenosynovial giant-cell tumor. J Clin Oncol 23:3847-3848, 2005 11. Jamieson KA, Beggs I, Robb JE: Synovial presentation of non-Hodgkin's lymphoma. Br J Radiol 71:980-982, 1998[Abstract] 12. Birlik M, Akar S, Onen F, et al: Articular, B-cell, non-Hodgkin's lymphoma mimicking rheumatoid arthritis: Synovial involvement in a small hand joint. Rheumatol Int 24:169-172, 2004[CrossRef][Medline] 13. Cheuk W, Chan AC, Chan JK, et al: Metallic implant-associated lymphoma: A distinct subgroup of large B-cell lymphoma related to pyothorax-associated lymphoma? Am J Surg Pathol 29:832-836, 2005[CrossRef][Medline] 14. Visuri T, Pulkkinen P, Paavolainen P: Malignant tumors at the site of total hip prosthesis: Analytic review of 46 cases. J Arthroplasty 21:311-323, 2006[CrossRef][Medline]
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Copyright © 2007 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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