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Keywords:

  • Peripheral T-cell lymphoma;
  • not otherwise specified (PTCL-NOS) of the thyroid;
  • spontaneous regression;
  • indolent T-cell lymphoma;
  • autoimmune thyroiditis;
  • array comparative genomic hybridization

Summary

  1. Top of page
  2. Summary
  3. Materials and methods
  4. Results
  5. Discussion
  6. Acknowledgements
  7. Authorships and disclosures
  8. References
  9. Supporting Information

Primary peripheral T-cell lymphoma, not otherwise specified (PTCL-NOS) of the thyroid is an extremely rare neoplasm. Six cases of primary PTCL-NOS of the thyroid were analysed for clinicopathological features and genomic alteration patterns using oligo-array comparative genomic hybridization. All patients had a diffusely enlarged thyroid and three cases showed leukaemic manifestation. Five of the six cases had anti-thyroid antibodies and the remaining case showed hypothyroidism, suggesting that all cases had autoimmune thyroiditis. Except for one early relapsed case, the remaining five patients are alive and three of these five individuals have survived for 70 months or more. Interestingly, two cases showed spontaneous regressions after partial thyroid biopsy without any therapy. Leukaemic manifestation disappeared after irradiation of the thyroid mass in another two cases. The tumour cells were positive for CD3, CD4 and CXCR3 in all cases, suggesting that the tumour cells are of a type 1 helper T-cell origin. All six cases showed genomic alterations that were different from those previously reported for PTCL-NOS. The loss of 6q24·2 was characteristic and was detected in four of the six cases. These results suggest that primary PTCL-NOS of the thyroid arising from autoimmune thyroiditis is a distinct disease entity among heterogeneous PTCL-NOS.

Peripheral T-cell lymphoma, not otherwise specified (PTCL-NOS) is one entity of the non-Hodgkin lymphomas referenced in the World Health Organization (WHO) classification (Pileri et al, 2009). It is the most frequent mature T- and NK-cell neoplasm entity and represents a heterogeneous group of nodal and extra-nodal mature T-cell lymphomas that do not belong to any of the recognized entities in the T cell lymphoma subtypes. Most patients with PTCL-NOS present with peripheral lymph node involvement, but any site may be affected (Pileri et al, 2009). PTCL-NOS is a highly aggressive lymphoid neoplasm with a poor response to therapy and shows frequent relapse. A high score for the international prognosis index (IPI) or prognostic index for peripheral T-cell lymphoma (PIT) is recognized and a large number of transformed cells, revealed by histopathological analysis, are related to poor prognosis (Gallamini et al, 2004; Vose et al, 2008; Weisenburger et al, 2011). Additionally, the expression of chemokine receptors and the presence of genomic aberrations in lymphoma cells are thought to have predictive value for patients with PTCL-NOS (Tsuchiya et al, 2004; Nakagawa et al, 2009; Hartmann et al, 2010).

Primary lymphomas of the thyroid account for only 2–4% of thyroid malignancies and less than 2% of extra-nodal lymphomas (Graff-Baker et al, 2009, 2010). The most common histopathological type in primary thyroid lymphomas is diffuse large B-cell lymphoma (DLBCL), and the second common type is mucosa-associated lymphoid tissue (MALT) lymphoma (Graff-Baker et al, 2009, 2010). In contrast, primary T-cell lymphoma of the thyroid is extremely rare, and such cases have been previously reported by several groups (Abdul-Rahman et al, 1996; Yamaguchi et al, 1997; Coltrera, 1999; Forconi et al, 1999; Freeman, 2000; Haciyanli et al, 2000; Raftopoulos et al, 2001; Koida et al, 2007; Graff-Baker et al, 2009, 2010).

We previously reported two cases of primary PTCL-NOS of the thyroid (hereafter referred to as primary thyroid T-cell lymphoma (PTTL)) (Koida et al, 2007). The lymphoma cells of those two cases were positive for CD4 and CXCR3, suggesting that the tumour cells originated from type 1 helper T lymphocytes (Th1). These two cases involved complicated autoimmune thyroiditis with an enlarged thyroid and were positive for anti-thyroid antibodies.

In the present study, six cases of PTTL including the previous two cases were examined and their clinicopathological features were investigated. We also investigated the genomic aberrations of PTTL by performing high-resolution oligo-array comparative genomic hybridization (CGH) using a 400 000 probe set. These analyses revealed that PTTL is a distinct entity of PTCL-NOS in regard to clinicopathological features and characteristic genomic aberrations.

Materials and methods

  1. Top of page
  2. Summary
  3. Materials and methods
  4. Results
  5. Discussion
  6. Acknowledgements
  7. Authorships and disclosures
  8. References
  9. Supporting Information

Patients

Six patients with PTTL were diagnosed between 2002 and 2011 at Nagasaki University Hospital, Kyoto University Hospital, and Tochigi Cancer Centre. Informed consent was obtained according to the Declaration of Helsinki from all patients. All patients with PTTL presented with an enlarged thyroid, and partial thyroidectomy was performed in five cases for pathological diagnosis. The remaining case had a needle biopsy for definitive diagnosis. After partial thyroidectomy for diagnosis, the lymphoma cells of Cases 3 and 4 showed spontaneous regression. The remaining four patients received chemotherapy. Detailed patient information is summarized in Tables 1, 2 and S1. The clinical course of each patient is provided as supplementary data.

Table 1. Patient information at diagnosis
CaseAge(years)SexEnlargedthyroidCSExtra-thyroidlesionsPSLDH >normalHistory of autoimmunethyroiditisPresence of anti-thyroid antibodies a
  1. CS, Clinical Stage; PS, Eastern Cooperative Oncology Group Performance Status; LDH, lactate dehydrogenase; M, Male; F, Female; PB, Peripheral Blood; BM, Bone Marrow; LN, Lymph node.

  2. a

    This indicated both anti-thyroglobulin antibody and anti-peroxidase antibody.

161MBilateralIVPB, BM1+
268MBilateralIIECervical LNs4+++
363FRightIIEA cervical LN1
451MBilateralIVCervical LNs, PB1++
567FBilateralIIECervical LNs1++
683MBilateralIVPB, BM1++
Table 2. Clinical courses of six analyzed patients
CaseInitial therapyEffect of initial therapyPFS (months)Spontaneous regressionTherapy at relapseOS (months)Outcome
  1. PFS, Progression-free Survival; OS, Overall Survival; COP, cyclophosphamide vincristine and prednisolone; CHOP, cyclophosphamide doxorubicin vincristine and prednisolone; THP-COP, pirarubicin cyclophosphamide vincrisitine and prednisolone; PR, Partial Response; IT, intrathecal chemotherapy.

  2. a

    After only irradiation to thyroid, tumor cells in peripheral blood spontaneously disappeared in these cases.

1Chemotherapy (COP)PR57+aRadiotherapy (thyroid) 46 Gy120Survival without lymphoma
2Chemotherapy (CHOP)PR4Chemotherapy (IT)5Death
3Only biopsy  + 15Survival without lymphoma
4Only biopsy  + 97Survival without lymphoma
5Chemotherapy (CHOP)PR23Chemotherapy (COP)70Survival with lymphoma
6Chemotherapy (THP-COP)PR8+aRadiotherapy (thyroid) 40 Gy13Survival without lymphoma

Immunohistochemical study

Thyroid samples for histological diagnosis were formalin-fixed, paraffin-embedded and stained using a haematoxylin-eosin (H&E) method. Paraffin sections from each sample were immunostained with monoclonal antibodies against CD3 (Novocastra, Newcastle, UK), CD4 (MBL, Tokyo, Japan), CD8 (Novocastra), TIA1 (Coulter, Hialeah, FL, USA), CXCR3 (PharMingen, San Diego, CA, USA), CCR5 (R&D Systems, Minneapolis, MN, USA), and CCR4 (PharMingen). The tissue sample was considered positive if more than 30% of the lymphoma cells were positive. All histopathological analyses were performed in the Department of Pathology, Kurume University. In accordance with WHO criteria, the pathological diagnosis was made by two expert haematopathologists (Pileri et al, 2009).

DNA and RNA extraction

Frozen samples of thyroid were embedded in optimal cutting temperature (OCT) compound and sectioned for DNA and RNA purification. Peripheral blood mononuclear cells (PBMCs) were isolated using the Ficoll-Paque method. High molecular-weight DNA was extracted from the sections of thyroid or PBMCs using standard proteinase K treatment and the phenol-chloroform method (Seto et al, 1992). Total RNA was extracted from the sections of thyroid tissue using Trizol reagent (Invitrogen, Carlsbad, CA) according to the manufacturer's protocol.

Oligo-array CGH and Gene expression profiling analyses

We performed array CGH analysis using 400K high-resolution oligo-array CGH slides (Agilent, Cat# G4448A; Agilent Technologies, Santa Clara, CA, USA) for these samples. Normal human male genomic DNA obtained from a pool of eight normal male PBMCs was used in all experiments as a reference sample. Procedures for DNA digestion, labeling, hybridization, scanning and data analyses were performed according to the manufacturer's protocol (www.agilent.com). Analysis of the log2 ratio was conducted in accordance with our previous report (Umino et al, 2011). We considered loss regions with a log2 ratio <−1·0 as homozygous deletions. Copy number variations/polymorphisms (CNVs) were identified using a web database (http://projects.tcag.ca/variation/) and then excluded from further analyses. Analysis of gene expression profiling was performed as described previously (Karube et al, 2011). Gene Set Enrichment Analysis (GSEA; http://www.broad.mit.edu/gsea) was adapted to analyse the difference between PTCL-NOS and PTTL (Subramanian et al, 2005) (see details in Supplemental data, Methods section).

Semi-quantitative reverse transcription polymerase chain reaction (RT-PCR)

Semi-quantitative RT-PCR was performed essentially as described previously (Karube et al, 2011) (see details in Supplemental data, Methods section).

Preparation of normal CD4-positive T-lymphocytes

Peripheral blood mononuclear cells were obtained from six healthy volunteers using the Ficoll-Paque method. Purification of CD4-positive T-lymphocytes was performed in accordance with the magnetic-activated cell-sorting protocol (Miltenyi Biotec) as described previously (Umino et al, 2011).

Statistical analysis

Prognosis was evaluated by overall survival (OS) and progression-free survival (PFS). OS was calculated from the date of diagnosis to death or the last date of follow-up. PFS was calculated from the date of initial therapy to the first date of disease progression, relapse, death as a result of any cause, or the last date of follow-up. Survival was evaluated using the Kaplan-Meyer method. Genomic aberration patterns of PTTL and those of previously reported PTCL-NOS were compared using Fisher's exact test (Nakagawa et al, 2009; Hartmann et al, 2010). These statistical tests were performed using R software. A P value <0·05 was considered statistically significant in these tests.

Array CGH and gene expression data accession number

The array CGH data obtained in this study have been submitted to ArrayExpress and the assigned accession numbers are E-MTAB-1186 (array CGH) and E-MTAB-1411 (gene expression profiling).

Results

  1. Top of page
  2. Summary
  3. Materials and methods
  4. Results
  5. Discussion
  6. Acknowledgements
  7. Authorships and disclosures
  8. References
  9. Supporting Information

Indolent clinical course of PTTL

The patients characteristics are summarized in Tables 1 and 2. Median age at diagnosis of the six cases was 65 years (range: 51–83). All patients had a diffusely enlarged thyroid. Four of the six cases had cervical lymphadenopathy, but none of the six cases showed any other lymphadenopathy. Three cases showed leukaemic manifestation (Cases 1, 4 and 6) and two of these three had bone marrow involvement (Cases 1 and 6). Poor performance status and a high lactate dehydrogenase value were observed in one patient (Case 2).

Four cases had a history of autoimmune thyroiditis and five cases had anti-thyroglobulin and anti-thyroid peroxidase antibodies. The remaining patient without these antibodies (Case 3) showed a high thyroid stimulating hormone (TSH) level, suggesting hypothyroidism (Table S1). Five cases were diagnosed by partial thyroidectomy and Case 6 was diagnosed by needle biopsy.

After diagnosis, Case 1 was treated with COP (cyclophosphamide, vincristine and prednisolone) therapy, Cases 2 and 5 were treated with CHOP (cyclophosphamide, doxorubicin, vincristine and prednisolone) therapy and Case 6 with THP-COP (pirarubicin, cyclophosphamide, vincristine, and prednisolone) therapy (Table 2). Cases 3 and 4 were followed up without any therapy. Median follow up duration was 43 months. Five cases are still alive (82%), three of whom have remained alive for 70 months or more. Case 2 showed early relapse at the central nervous system after initial therapy, and the patient died of lymphoma (Fig 1 and Table 2). Three cases (Cases 1, 5 and 6) achieved partial remissions (PRs) after initial chemotherapy. After relapse in the thyroid and peripheral blood (PB), Cases 1 and 6 received radiation therapy at the thyroid with 46 and 40 Gy, respectively. After irradiation, both achieved complete remissions (CRs) of PTTL with disappearance of leukaemic cells and thyroid tumour (Table 2).

image

Figure 1. Overall survival (OS) of patients with PTTL. The median follow-up duration was 43 months. Only one of six PTTL patients died (after 5 months, Case 2).

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Cases 3 and 4 did not receive any therapy and showed spontaneous regression of the enlarged thyroid and cervical lymphadenopathy after partial thyroidectomy for pathological diagnosis. The tumour cells in PB of Case 4 also disappeared spontaneously (Table 2). The majority of PTTL showed indolent clinical courses. Four of the six PTTL cases demonstrated spontaneous regression and one of the remaining two cases is stable while possessing lymphoma cells. Only one case demonstrated rapid progression and the patient died of lymphoma (Fig 1 and Table 2).

Morphological and immunohistological features

Morphological and immunohistological features are summarized in Table 3. Tumour cell size of PTTL was small to medium except for Case 2 (Figs 2A and 2B). Lymphoepithelial lesions (LEL) were recognized in four cases (Table 3). All six cases in this study were of a T-cell origin because tumour cells were positive for CD3 and CD4 (Fig 2C and Table 3). All of the four cases examined using Southern blot analysis (SRL Inc., Tachikawa, Tokyo, Japan) showed T-cell receptor (TCR) beta rearrangement (Cases 1, 4, 5 and 6). It is suggested that tumour cells of PTTL are of a Th1 cell origin since all six cases showed CD4 and CXCR3 positive tumour cells (Figs 2C, 2D and Table 3) (Tsuchiya et al, 2004; Groom & Luster, 2011). Flow cytometrical analyses were conducted for Cases 1, 2 and 4. Cases 1 and 2 were positive for CD45RO and Case 4 was positive for CD45RA (data not shown).

Table 3. Results of pathological and immunohistochemical findings
CaseDiagnosisSize of lymhoma cellsLELCD3CD4CD8TIA1CXCR3CCR5CCR4
  1. PTCL-NOS, Peripheral T-cell Lymphoma not otherwise specified; LEL, lymphoepithelial lesion.

1PTCL-NOSSmall to medium+++++
2PTCL-NOSDiffuse, large++++
3PTCL-NOSSmall to medium+++++
4PTCL-NOSSmall to medium++++
5PTCL-NOSSmall to medium++++
6PTCL-NOSSmall to medium++++
image

Figure 2. Morphological and immunohistochemical features of PTTL Case 4. Representative histopathological features of Case 4. (A) The thyroid architecture is effaced by diffuse proliferation of tumour cells (Haematoxylin & Eosin [H-E], original magnification ×40). (B) Small to medium-sized lymphoma cells show nuclear irregularity (H-E original magnification ×100). The lymphoma cells express CD4, (C) and CXCR3 (D) (both original magnification ×200).

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Genomic aberration patterns of PTTL

Figures 3A and S1 show the results of oligo-array CGH analysis for the six cases investigated in this study. The aberration regions found in more than three cases are summarized in Table 4. Gains of 4p16·3, 4p17, 7q22, 8q24·3, 9q33·3, 17q25·3 and the short arm of chromosome 19, and loss of 6q23-qter were frequently observed. Among these aberrations, the gains of 4p16·3, 4p17, 8q24·3, 9q33·3, 17q25·3 and the short arm of chromosome 19, and the loss of 6q23-qter were significantly characteristic of PTTL (P-value <0·05) when compared with previously reported PTCL-NOS. The relatively frequent aberrations identified in previously reported PTCL-NOS such as gain of 2p15-16 and loss of 17p13 (Nakagawa et al, 2009; Hartmann et al, 2010) appear to be less frequent in PTTL.

Table 4. Aberration regions of primary PTCL-NOS of the thyroid
Aberration typeChromosome bandRepresentative genesNumber of cases (PTTL) n = 6 (%)Sample identity of case(s) with gain or lossNumber of cases (PTCL-NOS) n = 47 (%)Fisher P-valuebNumber of cases (PTCL-NOS) n = 51 (%)FisherP-valuec
  1. PTCL-NOS, peripheral T-cell lymphoma not otherwise specified; PTTL, Primary Thyroid T-cell Lymphoma; NA, Not Available.

  2. a

    These were frequent aberration regions of previously reported PTCL-NOS.

  3. b

    P-values for diferrences between PTTL and PTCL-NOS reported by Hartmann et al (2010) (n = 47).

  4. c

    P-values for differences between PTTL and PTCL-NOS reported by Nakagawa et al (2009) (n = 51).

  5. Both results were available, the P-values were corrected by Bonferonni adjustment. Bold values indicate P < 0·05.

Gain1q41a DUSP10 1 (17)Case 26 (13)1·002 (4)0·86
2p15-16a REL, PEX13, AHSA2 0 8 (17)1·002 (4)1·00
4p16·3e.g. MYL5, CPLX1, GAK, etc.3 (50)Cases 2, 4, 5NA 6 (12) 0·0441
4p17 SH3BP2 3 (50)Cases 2, 4, 5NA 5 (10) 0·0308
7q22

FBXO24, MOSPD3,

PCOLCE, TFR2

3 (50)Cases 2, 4, 511 (23)0·978 (16)0·24
8q24·3e.g. BOP1, etc.3 (50)Cases 2, 4, 5NA 4 (8) 0·0201
9q33·3 RABEPK, GAPVD1 3 (50)Cases 2, 3, 4NA 6 (12) 0·0441
11q23-24ae.g. TIRAP, IL10RA, etc.1 (17)Case 26 (13)1·007 (14)1·00
17q25·3 ASPSCR1 3 (50)Cases 1, 2, 6NA 4 (8)0·012
19p13·3-p13·11e.g. JAK3, DNMT1, etc.3 (50)Cases 2, 3, 4NA 2 (4) 0·00627
Loss6q23-24·2e.g. TNFAIP3, etc.3 (50)Cases 1, 4, 5NA 5 (10) 0·0308
6q24·2 STX11, UTRN 4 (67)Cases 1, 4, 5, 6NA 5 (10) 0·0041
6q24·2-6q24·3e.g. EPM2A, FBXO30, etc.3 (50)Cases 1, 4, 5NA 7 (14)0·0602
7p14 TRG@ 3 (50)Cases 1, 5, 617 (36)0·661NA 
7q34 TRB@ 3 (50)Cases 1, 2, 66 (13)0·0539NA 
9p21a CDKN2A, CDKN2B 1 (17)Case 25 (11)1·0014 (27)1·00
10p11e.g. KIF5B, EPC1, etc.2 (33)Cases 4, 57 (15)0·805 (10)0·406
10p12a ARMC4, MPP7, WAC, BAMBI 1 (17)Case 59 (19)1·005 (10)1·00
14q11 TRA@ 5 (83)Cases 1, 2, 3, 5, 635 (74)0·286NA 
17p13ae.g. TP53, etc.0 (0) 5 (11)1·0011 (22)1·00
image

Figure 3. Characteristic genomic aberrations of PTTL patients. (A) Frequency of genomic aberrations of six PTTL patients. The regions of copy number variations/polymorphisms (CNVs) were not removed. Horizontal axis indicates each probe that is aligned from chromosome 1 to 22 and the short arm (p) to long arm (q). Vertical axis indicates the frequency of genomic aberrations among the analysed cases. The upper area represents gain and the lower area represents loss. (B) Genomic aberration of chromosome 6q23.2-qter was the most frequently deleted region of the whole genome, except for the T-cell receptor α locus at 14q11.3 and CNV at 14q24.3. Four cases with a deletion of 6q24.2 are shown. A black horizontal bar indicates the deleted region of each case. The minimum deleted region in Case 6 is as small as 41 Kb. This deleted region includes only two genes, STX11 and UTRN.

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The most frequent aberration is loss of 6q24·2, which was found in four cases (67%). The narrowest deleted region of 6q24·2 among the four cases was found in Case 6. In Case 6, genomic aberration of the bone marrow (BM) cells that contain an undetectable level of tumour cells was also analysed (Fig S2). The PB sample containing more tumour cells (Table S1) showed genomic deletion of 6q24·2, but the deletion was not observed in the BM sample. This result indicated that the loss in this particular case was not one of the CNVs. This region was therefore considered the most frequently deleted minimal common region (MCR) where only two genes existed, STX11 and UTRN (Figs 3B and S3).

The homozygous loss of 9p21·3 including CDKN2A and CDKN2B was observed in Case 2, which had an aggressive clinical course (Table S2). There were no other recurrent homozygous losses in PTTL except for the regions encoding TCR α and TCR γ chains. We performed oligo-array CGH for both PB and thyroid samples in Case 1. The results of these genomic aberration patterns were similar to each other, although noise is high with thyroid tissue (Fig S1).

Gene expression profiling and semi-quantitative analysis of PTTL

Gene expression profiles were analysed in PTLL samples, PTCL-NOS samples, and normal CD4-positive T-lymphocytes. Based on these results, GSEA was used to detect gene sets whose expression levels differed between PTTL and PTCL-NOS (Fig S4 and Tables S3 and S4). This analysis revealed that cell cycle and mitosis-related gene sets were significantly enriched in PTCL-NOS samples compared to PTTL samples.

STX11 and UTRN expression in MCR were analysed in PTTL samples, PTCL-NOS samples, and normal CD4-positive T-lymphocytes. The probes used in gene expression profiling showed that both STX11 and UTRN expression were more reduced in PTTL and PTCL-NOS than in normal CD4-positive T-lymphocytes (Fig S5A). Semi-quantitative RT-PCR was also adapted to analyse STX11 and UTRN expression (Fig S5B). UTRN expression increased to a greater degree in PTTL and PTCL-NOS clinical samples than in normal CD4-positive T-lymphocytes. Three of four PTTL samples and one of six PTCL-NOS samples showed lower STX11 expression when compared with normal CD4-positive T-lymphocytes. Although the two cases with the 6q deletion tended to express STX11 at a lower level, a case without 6q deletion (Case 2) showed a remarkably low STX11 expression.

Discussion

  1. Top of page
  2. Summary
  3. Materials and methods
  4. Results
  5. Discussion
  6. Acknowledgements
  7. Authorships and disclosures
  8. References
  9. Supporting Information

Clinicopathological features of PTTL

Primary PTCL-NOS of the thyroid is an extremely rare neoplasm. We investigated six cases of PTTL. Five of these cases exhibited autoimmune thyroiditis and the remaining case showed a high level of TSH, suggesting that all six PTTL cases arose in a background of autoimmune thyroiditis. We analysed the clinical courses, histopathological findings, and genomic aberration profiles of these cases in detail. Although one patient had an aggressive clinical course, two patients had spontaneous regression of lymphoma without any therapy. Among the remaining three patients, two showed disappearance of leukaemic manifestation after irradiation of the relapsed thyroid tumour after chemotherapy, and one remained stable in PR after chemotherapy, suggesting that the clinical course of most PTTL is indolent and characterized by spontaneous regression. All lymphoma cells were positive for CD4 and CXCR3, and the genomic aberration patterns were quite different from those of PTCL-NOS. GSEA also revealed significant differences for gene expression profiles associated with the cell cycle and mitosis between PTTL and PTCL-NOS. It can therefore be suggested that PTTL is a distinct entity of mature T-cell neoplasms among PTCL-NOS.

The loss of CDKN2A/2B found in PTTL with an aggressive course

Case 2, who had an early relapse and died of lymphoma at five months, showed different lymphoma cell morphology. The lymphoma cells of Case 2 were large in size and different from those of the other five cases, which showed cells of a small to medium size. This case showed characteristic genomic aberrations in PTTL, such as gains of 4p16, 4p17, 8q24·3, 9q33·3 and 19p13·3-p13·11, as found in the other PTTL samples. It is noted that this case also had characteristic genomic aberrations found in previously reported PTCL-NOS, such as gains of 1q41 and 11q23. Homozygous loss of 9p21·3 was also found in this case (Table 4 and Table S2) (Nakagawa et al, 2009; Hartmann et al, 2010). The loss of the 9p21·3 region containing CDKN2A and CDKN2B, which are regarded as tumour suppressor genes, is associated with poor prognosis in various malignancies, including malignant lymphoma (Hatta & Koeffler, 2002; Tagawa et al, 2005; Lenz et al, 2008). The aggressive clinical course of Case 2 might be associated with acquisition of the loss of 9p21·3 among indolent PTTL cases.

Spontaneous regression, radiation-sensitivity and favourable prognosis of PTTL

Although one of the six PTTL patients died from a relapse of the disease, all the other patients remain alive with/without treatment, and three of the five patients have remained alive for 70 months or more (Fig 1). The 5-year OS rate of PTCL-NOS was reported to be 36%,(Weisenburger et al, 2011) and that of PTCL-NOS with genomic aberrations was approximately 10% (Nakagawa et al, 2009; Hartmann et al, 2010). Tsuchiya et al (2004) demonstrated that the expression of CXCR3 was associated with favourable prognosis, but the 5-year OS rate of PTCL-NOS with CXCR3 expression was approximately 50%. These data suggest that the majority of PTTL have indolent clinical courses.

It is interesting to note that two cases of PTTL showed spontaneous regression of lymphoma without any therapy. Although the spontaneous regression of T cell lymphoma is very rare, this finding may be quite characteristic of PTTL. Cases 1 and 6 achieved CR of PTTL in PB and the thyroid after irradiation of the thyroid. This finding suggests that tumour cells of PTTL proliferate in the thyroid and overflow into PB.

Cell origin of PTTL

Lymphoma cells of all six cases were positive for CD4 and CXCR3. CXCR3 is one of the inflammatory chemokine receptors and is expressed on Th1 and CD8 positive cytotoxic T-cells (Groom & Luster, 2011). Five of the present cases had a history of autoimmune thyroiditis and the remaining case showed hypothyroidism, suggesting that all cases had a history of autoimmune reaction against the thyroid. This suggests that the cell origin of PTTL is derived from T-cells that invaded inflammatory lesions of the thyroid. Indeed, the majority of T-cells that invade inflammatory lesions of autoimmune thyroiditis have been shown to be Th1-like T-cells positive for CD4, CXCR3 and CCR5 (Garcia-Lopez et al, 2001; Rotondi et al, 2003). In this regard, it is important to note that irradiation on a relapsed enlarged thyroid in Cases 1 and 6 resulted in CR with disappearance of thyroid tumour and leukaemic manifestation. This is consistent with the assumption that the lymphoma cell origin involves Th1 that invaded inflammatory lesions of autoimmune thyroiditis.

All except one (a γδ T-cell lymphoma) of the nine primary thyroid T-cell lymphomas previously reported from other institutions (Abdul-Rahman et al, 1996; Yamaguchi et al, 1997; Coltrera, 1999; Forconi et al, 1999; Freeman, 2000; Haciyanli et al, 2000; Raftopoulos et al, 2001), may belong to the same disease entity as the present cases, although the reported cases from the other institutions were not analysed in detail and did not investigate chemokine receptors.

Loss of UTRN and STX11 in PTTL

Oligo-array CGH revealed genomic aberrations in all six PTTL cases. The aberration pattern of PTTL is quite unique and the loss of 6q23-qter was the most frequently detected. Although the deletion of 6q24·2 was also observed in mantle cell lymphoma (Liu et al, 2013), as well as acute-type and chronic-type adult T-cell leukaemia/lymphoma, the frequency of this aberration was not as high as that of PTTL in comparison to those of the other types of lymphoma (Fig S6). These data suggest that the 6q24·2 deletion is characteristic of PTTL.

MCR of this loss region contained two genes, UTRN and STX11. The UTRN mutation was observed in approximately 20–30% of patients with breast cancer, glioblastoma and malignant melanoma (Li et al, 2007). Among these mutations, one breast cancer case showed a nonsense mutation and the other cases showed frame shift mutations. Thus, loss of function in UTRN caused by mutation is thought to be involved in tumourigenesis (Li et al, 2007). Heterozygous loss of UTRN has also been reported in chondromyxoid fibroma by fluorescent in situ hybridization analysis (Romeo et al, 2010). Therefore, UTRN is regarded as a tumour suppressor gene. The deletions or nonsense mutations in STX11 are known to cause familial haemophagocytic lymphohistiocytosis type 4 (FHL4) (Rudd et al, 2006). Patients with FLH are characterized by defective natural killer (NK)-cell activity, polyclonal T-cell expansion, and lymphohistiocytic infiltration of visceral organs (Bryceson et al, 2007).

We could not perform mutation analysis for UTRN and STX11 because of the limited availability of samples. However, both UTRN and STX11 expression could be analysed using gene expression profiling and semi-quantitative RT-PCR. The results suggested that STX11 is likely to be the candidate gene for PTTL. However, it should be noted that the RNAs analysed in this study were derived from both tumour cells and thyroid tissues. This might also influence the expression levels of these two genes. Gene expression and mutation analyses on purified tumour cells and a functional study are needed to further clarify the significance of these genes for development and the clinicopathological features of PTTL.

The frequent losses of UTRN and STX11 have not yet been reported in malignant lymphoma including PTCL-NOS. Therefore, this result also supports the idea that PTTL may be a distinct entity of mature T-cell neoplasms among PTCL-NOS.

Taken together, the loss of UTRN and/or STX11 might play an important role in tumourigenesis of PTTL in a background of autoimmune thyroiditis as analysed in this study. Further study detailing the roles of these genes in the pathogenesis of PTTL will be required in the future.

Autoimmune thyroiditis has been implicated in the development of MALT lymphoma of a B cell origin (Isaacson et al, 2009). The cases analysed in this study are thought to be thyroid PTCL-NOS of a Th1 cell origin associated with autoimmune thyroiditis. In this regard, this PTTL may be a T-cell malignancy corresponding to MALT lymphoma of a B cell origin developed in the inflammatory reaction and could be recognized as a distinct T-cell neoplasm among PTCL-NOS. A suitable designation for this disease may be primary thyroid CXCR3-positive peripheral T-cell lymphoma.

Acknowledgements

  1. Top of page
  2. Summary
  3. Materials and methods
  4. Results
  5. Discussion
  6. Acknowledgements
  7. Authorships and disclosures
  8. References
  9. Supporting Information

The authors thank Drs. Kennosuke Karube, Kotaro Arita and Shinobu Tsuzuki for their critical discussions and encouragement throughout this study. This work was supported in part by Grants-in-Aid from the Ministry of Health, Labour and Welfare, from the Ministry of Education, Culture, Sports, Science and Technology, from the Japan Society for the Promotion of Science, by Grants-in-Aid [Grant Numbers 21-6-3, 23120601] for Cancer Research from the Ministry of Health, Labour and Welfare of Japan, by the National Cancer Centre Research and Development Fund (23-A-17) and by Izumo City Supporting Cancer Research Project Fund.

Authorships and disclosures

  1. Top of page
  2. Summary
  3. Materials and methods
  4. Results
  5. Discussion
  6. Acknowledgements
  7. Authorships and disclosures
  8. References
  9. Supporting Information

N.Y., M.Se., M.Shi., and K.T. designed research, N.Y., D.N., and K.O performed research, M.N., T.I., Y.I., Y.S., M.T., S.H., and K.T. collected data, N.Y., M.Shi., M.Se., and K.T. analysed and interpreted data, N.Y. performed statistical analysis, and N.Y., M.Se., M.Shi., and K. T wrote the manuscript. The authors declare no competing financial interests.

References

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  2. Summary
  3. Materials and methods
  4. Results
  5. Discussion
  6. Acknowledgements
  7. Authorships and disclosures
  8. References
  9. Supporting Information
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Supporting Information

  1. Top of page
  2. Summary
  3. Materials and methods
  4. Results
  5. Discussion
  6. Acknowledgements
  7. Authorships and disclosures
  8. References
  9. Supporting Information
FilenameFormatSizeDescription
bjh12255-sup-0001-SupplementaryData.pdfapplication/PDF1269K

Fig S1. All genomic profiles of the six analyzed cases.

Fig S2. Genomic aberrations of both peripheral blood and bone marrow samples in Case 6.

Fig S3. Genomic aberration of 6q24.2.

Fig S4. Difference between PTTL and PTCL-NOS using Gene Set Enrichment Analysis.

Fig S5. UTRN and STX11 expressions in PTTL.

Fig S6. Frequency of genomic aberration on chromosome 6q in various types of malignant lymphoma.

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