Role of reactive perivascular lymphocytic infiltrate in primary central nervous system lymphoma
Department of Anatomic Pathology, William Beaumont Hospital, Royal Oak, MI 48076, USA
Department of Anatomic Pathology, William Beaumont Hospital, Royal Oak, MI 48076
|How to cite this article:|
Bhagavathi S. Role of reactive perivascular lymphocytic infiltrate in primary central nervous system lymphoma.J Postgrad Med 2009;55:240-241
|How to cite this URL:|
Bhagavathi S. Role of reactive perivascular lymphocytic infiltrate in primary central nervous system lymphoma. J Postgrad Med [serial online] 2009 [cited 2020 Sep 29 ];55:240-241
Available from: http://www.jpgmonline.com/text.asp?2009/55/4/240/58924
In this issue of Journal of Postgraduate Medicine, Kumari et al.,  report their experience of 30 patients with primary central nervous system lymphoma (PCNSL) of the diffuse large B-cell subtype. These cases were categorized according to the international extra-nodal lymphoma study group (IELSG) score. Authors have attempted to clarify the association between the morphological features, such as reactive perivascular lymphocytic infiltrate (RPVLI) and necrosis, with IELSG score. The majority of the patients in this study had an intermediate (23/30) and high-risk (4/30) IELSG score. Seven (two with low-risk and five with high-risk IELSG score) and eight (one with low-risk, six with intermediate, and one high-risk IELSG score) patients with PCNSL showed RPVLI and necrosis respectively. However, this study failed to show association between IELSG score, RPVLI, and necrosis.
Primary CNS lymphoma is an extra-nodal, non-Hodgkin lymphoma that involves the brain, leptomeninges, eyes, and spinal cord. It occurs in both immunocompromised and immunocompetent patients. Although the incidence of PCNSL in immunocompetent patients has increased over the last few decades, recent literature reports the stabilization of its incidence. The majority of PCNSL are diffuse large B-cell subtype with rare occurrence of other B-cell and T-cell lymphoma. The overall survival (OS) rate for PCNSL is low compared to other extra-nodal lymphomas.
Ferrieri et al., have reported a prognostic scoring system for PCNSL with five parameters: age, performance status, serum LDH level, cerebrospinal fluid (CSF) protein level, and the location of lymphoma in the CNS.  For each parameter, they gave a score of 0 (favorable) or 1 (unfavorable), and divided PCNSL into low (0 to1), intermediate (2 to 3), and high-risk (4 to 5) categories. In their study they showed that an age higher than 60 years, a performance status greater than 1, an elevated serum LDH, and CSF protein levels and location of lymphoma deep in the CNS (basal ganglia, brainstem, periventricular area, and cerebellum) are associated with bad prognosis. A majority of patients with PCNSL in the study performed by Ferrieri et al., belonged to the intermediate- or high-risk category. Various other factors contributing to the low OS of PCNSL include having activated B-cell (ABC) subtype, , high BCL2, and MIB-1 index. 
Even though clinical, and biochemical parameters are validated in prognostication of PCNSL, histopathological parameters, which are quite easy to report, are scarce. The reactive immune T-cell response has been studied previously in various malignancies, including lymphomas. Ansell et al.,  have studied the extent of the reactive T-cell immune response by flow cytometry in patients with diffuse large B-cell lymphoma. They have reported that the increased CD4-positive T-cells in tumor samples with lymphoma predict better prognosis. Ponzoni et al.,  studied the effect of RPVLI and necrosis on OS in patients with PCNSL. They reported that RPVLI, instead of necrosis, is associated with better survival in PCNSL. Interestingly, RPVLI is independent of IELSG score in prognostication of PCNSL. This study is not yet validated in clinical trials.
What are the strengths of the present study? It includes a relatively large number of PCNSL, which is a rare condition, from India. The paper also elaborates in detail clinical and pathological features.
What are the weaknesses of this study? The patients with treatment history (14/30) and follow-up (13/30) are less than 50% of the study population. Above all, the follow-up period is short. The authors should have statistically analyzed the effect of RPVLI and necrosis on OS instead of correlating it with IELSG score by univariate and multivariate analysis.
What are the questions this report generates? First of all, the prognostic role of RPVLI in cases of PCNSL needs to be clarified in a large prospective study due to the uncertainty about its utility in prognosis. If RPVLI shows promise as a parameter of good prognosis, then clinical trials of patients with PCNSL with an aim to modulate immune response need to be conducted to validate its clinical utility.
Despite a few shortcomings, the authors need to be congratulated for making an attempt to characterize the role of RPVLI and necrosis in PCNSL.
|1||Kumari N, Krishnani N, Rawat A, Agarwal V, Lal P. Primary central nervous system lymphoma: Prognostication as per international extranodal lymphoma study group score and reactive CD3 collar. J Postgrad Med 2009;55:247-51.|
|2||Ferreri AJM, Blay JY, Reni M, Pasini F, Spina M, Ambrosetti A, et al. Prognostic scoring system for primary CNS lymphoma: The international extranodal lymphoma study group experience. J Clin Oncol 2003;21:266-72.|
|3||Camilleri-Broet S, Criniere E, Broet P, Delwail V, Mokhtari K, Moreau A, et al. A uniform activated B-cell like immunophenotype might explain the poor prognosis of primary central nervous system lymphomas: Analysis of 83 cases. Blood 2006;107:190-6.|
|4||Bhagavathi S, Sharathkumar A, Hunter S, Sung L, Kanhere R, Venturina MD, et al. Activated B-cell phenotype might be associated with poor prognosis of primary central nervous system lymphomas. Clin Neuropathol 2008;27:13-20.|
|5||Ansell SM, Stenson M, Habermann TM, Jelinek DF, Witzig TE. CD4 + T-cell immune response to large B-cell non-Hodgkin lymphoma predicts patient outcome. J Clin Oncol 2001;19:720-6.|
|6||Ponzoni M, Berger F, Chassagne-Clement C, Tinguely M, Jouvet A, Ferreri AJ, et al. Reactive perivascular T-cell infiltrate predicts survival in primary central nervous system B-cell lymphomas. Br J Haematol 2007;138:316-23.|