Hepatosplenic T cell lymphoma
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Associate Editor(s)-in-Chief: Jogeet Singh Sekhon, M.D. [3]
Synonyms and Keywords: Hepatosplenic γδ T-cell lymphoma, Hepatosplenic gamma delta T-cell lymphoma, HSTCL
Overview
Hepatosplenic T cell lymphoma is a rare type of non Hodgkins lymphoma that occurs in states of immunosupression such as post organ transplant and treatment of inflammatory bowel disease. Hepatosplenic T cell lymphoma was discovered by Farcet et al in 1990. It is also known as "gamma-delta" hepatosplenic T-cell lymphoma. The lymphoma is characterized by malignant T-cell proliferation in the sinusoids of the liver, sinuses and red pulp of the spleen, and sinuses of the bone marrow. The incidence of hepatosplenic t cell lymphoma is 0.3 per 100000 individuals per year. If left untreated, patients can develop liver failure, pancytopenia or spleen rupture. Biopsy of the tumor is the gold standard diagnostic test for diagnosing hepatosplenic T-cell lymphoma. Chemotherapy including CHOP is the mainstay of the treatment along with bone marrow transplant and radiation therapy.
Historical Perspective
Hepatosplenic T cell lymphoma was discovered by Farcet et al in 1990.
Classification
There is no established system for the classification of hepatosplenic t cell lymphoma.
Pathophysiology
- Hepatosplenic T-cell lymphoma is a peripheral T-cell lymphoma, a type of non Hodgkin's lymphoma.[1]
- It is also known as "gamma-delta hepatosplenic T-cell lymphoma".[2]
- It usually occurs in young men with history of immunosuppression including solid organ transplantation.[3]
- Patients with inflammatory bowel disease receiving immunosuppressants and anti-tumor necrosis factor-α agent are also at risk for developing hepatosplenic T-cell lymphoma.
- The T-cell receptor consists of either a gamma delta or alpha-beta entity on their cell surface which are a part of the innate immune system.[4][5]
- Gamma delta T cells represent the first line of defense against bacterial peptides, such as heat-shock proteins.
- Gamma delta T cells are CD4 and CD8 negative, but CD56 positive which is NK cell marker.
- Gamma delta cells respond to a stimulus and are responsible for lymphokine production and proliferation.
- Gamma delta cells are predominantly located in the spleen, liver sinusoids and intestinal epithelium.
- 75 % of the cases are of gamma delta phenotype and the rest are apha beta phenotype.
- Chronic antigen stimulation in states of immunosuppression is responsible for the development of the lymphoma.
- Isochromosome of the long arm of chromosome 7 is a genetic abnormality described in hepatosplenic t cell lymphoma. It could also be in association with trisomy 8 and a loss of a sex chromosome.
- Mutations in SETD2, INO80, TET3 and STAT5B occur exclusively in hepatosplenic T cell lymphoma as compared to other T and B cell lymphoma types.
- The lymphoma is characterized by malignant T-cell proliferation in the sinusoids of the liver, sinuses and red pulp of the spleen, and sinuses of the bone marrow.
- Splenic involvement is characterized by diffuse involvement of the red pulp with small-to-medium-sized atypical lymphocytes.
- The atypical lymphocytes are present within the cords and sinuses of the red pulp.
- There occurs a complete loss of the white pulp.
- The liver also shows sinusoidal infiltration by neoplastic lymphoid cells.
- The bone marrow is characterized by neoplastic cells in the sinusoids.
- Bone marrow infiltration results in pancytopenia.
- The lymphoma cells are typically CD2+, CD3+, CD4−, CD5−, CD7+, CD8− CD42+, CD52+, CD76+, CD82+ with either gamma-delta or alpha-beta T-cell phenotypic receptor expression.
- It manifests as hepatosplenomegaly without peripheral lymphadenopathy.
- Pancytopenia and abnormal liver functions are the laboratory findings.
- Histology and immunohistochemistry of the tumor biopsy shows portal and sinusoidal infiltration by atypical small-to-medium sized lymphocytes with hyperchromatic nuclei and low mitotic activity.
Causes
Common causes of hepatosplenic t cell lymphoma are: [6][7]
- Inflammatory bowel disease
- Organ transplant patients (receiver)
- Immunosuppressive medications
- Thiopurines
- Infliximab
- Cyclophosphamide
- Vincristine
- Doxorubicin
Differentiating hepatosplenic t cell lymphoma from Other Diseases
Differential diagnosis for the lymphoma is based on the below table:
| Differentiating diagnosis of Lymphoma | Symptoms | Signs | Diagnosis | Additional Findings | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Fever | Rash | Diarrhea | Abdominal pain | Weight loss | Painful lymphadenopathy | Hepatosplenomegaly | Arthritis | Lab Findings | ||
| Lymphoma | + | – | – | + | + | – | + | – | Increase ESR, increased LDH | Night sweats, constant fatigue |
| Brucellosis | + | + | – | + | + | + | + | + | Relative lymphocytosis | Night sweats, often with characteristic smell, likened to wet hay |
| Typhoid fever | + | + | – | + | – | – | + | + | Decreased hemoglobin | Incremental increase in temperature initially and than sustained fever as high as 40°C (104°F) |
| Malaria | + | – | + | + | – | – | + | + | Microcytosis,
elevated LDH |
"Tertian" fever: paroxysms occur every second day |
| Tuberculosis | + | + | – | + | + | + | – | + | Mild normocytic anemia, hyponatremia, and | Night sweats, constant fatigue |
| Mumps | + | – | – | – | – | + | – | – | Relative lymphocytosis, serum amylaseelevated | Parotidswelling/tenderness |
| Rheumatoid arthritis | – | + | – | – | – | – | – | + | ESR and CRP elevated, positive rheumatoid factor | Morning stiffness |
| SLE | – | + | – | + | + | – | – | + | ESR and CRP elevated, positive ANA | Fatigue |
| HIV | – | – | – | + | + | + | – | + | Leukopenia | Constant fatigue |
Differentiating different types of T-cell Non-Hodgkin lymphoma. The gold standard for differentiation different types of Non-Hodgkin lymphoma is biopsy.
! colspan="12" align="center" style="background:#7d7d7d; color: #FFFFFF;" + |Non-Hodgkin's Lymphoma (T Cell Lymphoma)
|-
! colspan="2" align="center" style="background:#DCDCDC;" + |Precursor T-cell lymphoblastic leukemia/lymphoma
[8][9]
| align="left" style="background:#F5F5F5;" + |
- Precursor T-cell lymphomas
| align="left" style="background:#F5F5F5;" + |
| align="center" style="background:#F5F5F5;" + | + | align="center" style="background:#F5F5F5;" + | - | align="center" style="background:#F5F5F5;" + | - | align="left" style="background:#F5F5F5;" + |
- In most patients the mediastinal mass is anterior; associated with pleural effusions
- Can produce such complications as superior vena cava syndrome
- Skin and bone abnormalities
- Enlarged liver and/or spleen
- Tracheal obstruction
- Pericardial effusions
| align="left" style="background:#F5F5F5;" + |
| align="left" style="background:#F5F5F5;" + |
| align="left" style="background:#F5F5F5;" + |
- Blast-like cells with scant cytoplasm, convoluted nuclei, fine chromatin, indistinct nucleoli.
- Some lymphoblasts have cytoplasmic pseudopods
| align="left" style="background:#F5F5F5;" + |
- Males in their teens to early twenties
- Lymphadenopathy in cervical, supraclavicular, axillary ,and mediastinum
|-
! colspan="2" align="center" style="background:#DCDCDC;" + |T-cell granular lymphocytic
[10][11][12]
| align="left" style="background:#F5F5F5;" + |
- Clonal proliferation of CD8 T cells
- Constant immune stimulation
- Absence of homeostatic apoptosis
| align="left" style="background:#F5F5F5;" + |
| align="center" style="background:#F5F5F5;" + | - | align="center" style="background:#F5F5F5;" + | - | align="center" style="background:#F5F5F5;" + | - | align="left" style="background:#F5F5F5;" + |
| align="left" style="background:#F5F5F5;" + |
- Frequent infections
| align="left" style="background:#F5F5F5;" + |
| align="left" style="background:#F5F5F5;" + |
- Medium / large lymphocytes with abundant cytoplasm having azurophilic granules
| align="left" style="background:#F5F5F5;" + |May be associated with the following conditions:
- Monoclonal gammopathy of unknown significance (MGUS)
- B-chronic lymphocytic leukemia (B-CLL)
- Hairy cell leukemia
- Myeloid hypoplasia
|-
! colspan="2" align="center" style="background:#DCDCDC;" + |T-cell prolymphocytic leukemia
[13]
| align="left" style="background:#F5F5F5;" + |
- Abnormal proliferation of mature T cells (post thymic)
| align="left" style="background:#F5F5F5;" + |
| align="center" style="background:#F5F5F5;" + | + | align="center" style="background:#F5F5F5;" + | - | align="center" style="background:#F5F5F5;" + | - | align="left" style="background:#F5F5F5;" + |
| align="left" style="background:#F5F5F5;" + |
| align="left" style="background:#F5F5F5;" + |
| align="left" style="background:#F5F5F5;" + |
- Lymphocytes with abundant basophilic, nongranular cytoplasm, atypical nucleus
- Cytoplasmic protrusions (blebs)
| align="left" style="background:#F5F5F5;" + |
|-
! colspan="2" align="center" style="background:#DCDCDC;" + |Adult T cell leukemia/lymphoma
[14][15][16]
| align="left" style="background:#F5F5F5;" + |
- Mature T-cell lymphoma
- Human T-lymphotrophic virus 1 infection
| align="left" style="background:#F5F5F5;" + |
- Hepatosplenomagaly
- T-cell deficiency leading immunodeficiency causing opportunistic infection
| align="center" style="background:#F5F5F5;" + | + | align="center" style="background:#F5F5F5;" + | - | align="center" style="background:#F5F5F5;" + | - | align="left" style="background:#F5F5F5;" + |
| align="left" style="background:#F5F5F5;" + |
- Hypercalcemia
- Skin lesions
- Lytic bone lesions
- Elevated LDH
| align="left" style="background:#F5F5F5;" + |
- Adult T-cell leukemia cells are typically positive for:
- CD2
- CD4
- CD5
- CD8
| align="left" style="background:#F5F5F5;" + |
- Charecterstic leukemia cells with sharp nuclear indentations and a prominent nucleoli
- "Cloverleaf" or "flower" cells
| align="left" style="background:#F5F5F5;" + |
|-
! colspan="2" align="center" style="background:#DCDCDC;" + |Anaplastic large cell lymphoma
[17][18][19][20]
| align="left" style="background:#F5F5F5;" + |
- Mature T-cell lymphoma
| align="left" style="background:#F5F5F5;" + |
| align="center" style="background:#F5F5F5;" + | + | align="center" style="background:#F5F5F5;" + | + | align="center" style="background:#F5F5F5;" + | - | align="left" style="background:#F5F5F5;" + | Painless swelling in :
| align="center" style="background:#F5F5F5;" + |
- Skin rash
- Chest pain
- Abdominal pain
- Bone pain
| align="left" style="background:#F5F5F5;" + |Strongly immunoreactive for :
| align="left" style="background:#F5F5F5;" + |
- Nucleoli tend to be more prominent
- The cytoplasm may be either basophilic or eosinophilic and the cell might have many nuclei with dispersed or clumped chromatin
| align="center" style="background:#F5F5F5;" + |
- May be caused by textured breast implants
|-
! align="center" style="background:#DCDCDC;" + |Cutaneous T-cell lymphoma
! align="center" style="background:#DCDCDC;" + |Mycosis fungoides / Sézary syndrome
[21][22][23]
| align="left" style="background:#F5F5F5;" + |
- Mature T-cell Lymphoma
- The tumor cells originate from memory T cells or skin homing CD4+ T cells expressing cutaneous lymphocyte antigen (CLA) and chemokine receptors CCR4and CCR7.
- It is understood that cutaneous t cell lymphoma (maycosis fungoides, Sezary sydrome ) is the result of malignant T cell that derived from a mature CD41 CD45RO1 memory T cells.
| align="left" style="background:#F5F5F5;" + |
| align="center" style="background:#F5F5F5;" + | + | align="center" style="background:#F5F5F5;" + | + | align="center" style="background:#F5F5F5;" + | - | align="left" style="background:#F5F5F5;" + |
- Cutaneous manifestations
| align="left" style="background:#F5F5F5;" + |
- Lymphadenopathy
- May progress to Sezary syndrome
| align="left" style="background:#F5F5F5;" + |
- Beta F1+
- CD2-/+
- CD3+
- CD3- (CD4-positive variant)
- CD4+ (CD4-positive variant)
- CD4-
- CD5-
- CD7+/-
- CD8+
- CD8- (CD4-positive variant),
- Granzyme B+
- perforin+
| align="left" style="background:#F5F5F5;" + |
- Polymorphous inflammatory infiltrate in the dermis that contains small numbers of frankly atypical lymphoid cells
- These cells may line up individually along the epidermal basal layer
- The presence of spongiosis is highly suggestive of mycosis fungoides
| align="center" style="background:#F5F5F5;" + |
- Epidermal atrophy or poikiloderma
- Generalized itching(pruritus)
- Pain in the affected area of the skin.
- Insomnia
- Red (erythematous) patches scattered over the skin of the trunk and the extremities
|-
! rowspan="6" align="center" style="background:#DCDCDC;" + |Peripheral T-cell lymphoma
! align="center" style="background:#DCDCDC;" + |Subcutaneous panniculitis-like T-cell lymphoma
[24][25][26]
| align="left" style="background:#F5F5F5;" + |
- Mature T-cell lymphoma
| align="left" style="background:#F5F5F5;" + |
| align="center" style="background:#F5F5F5;" + | - | align="center" style="background:#F5F5F5;" + | - | align="center" style="background:#F5F5F5;" + | - | align="left" style="background:#F5F5F5;" + |Painless swellings on:
- Extremities
- Trunks
| align="left" style="background:#F5F5F5;" + |
| align="left" style="background:#F5F5F5;" + |Positive for:
| align="left" style="background:#F5F5F5;" + |
- Atypical lymphoid cells
- Fat necrosis
- Karyorrhexis
| align="left" style="background:#F5F5F5;" + |
- Subcutaneous panniculitis-like T-cell lymphoma can mimic the following conditions making it difficult to diagnose
- Begnign panniculitis
- Eczema
- Cellulitis
- Dermatitis
|-
! align="center" style="background:#DCDCDC;" + |Hepatosplenic T-cell lymphoma
[27][28][29]
| align="left" style="background:#F5F5F5;" + |
- Mature T-cell Lymphoma
- Inflammatory bowel disease
- Organ transplant patients (reciever)
- Immunosuppresent medications
- Thiopurines
- Infliximab
- Cyclophosphamide
- Vincristine
- Doxorubicin
| align="left" style="background:#F5F5F5;" + |
| align="center" style="background:#F5F5F5;" + | + | align="center" style="background:#F5F5F5;" + | + | align="center" style="background:#F5F5F5;" + | - | align="left" style="background:#F5F5F5;" + |Painless swelling in :
| align="center" style="background:#F5F5F5;" + |
| align="left" style="background:#F5F5F5;" + |
- CD2
- CD3
- CD7
- CD16
- CD56 or CD57
- TIA1
- Granzyme m
- Fas ligand
| align="left" style="background:#F5F5F5;" + |
- Intermediate sized tumor cells with clear cytoplasm, oval nuclei, slightly dispersed condensed chromatin, inconspicuous nucleoli
| align="left" style="background:#F5F5F5;" + |
- Patients with inflammatory bowel diseases taking immunosuppressant and anti-tumor necrosis factor-α agent are also have a higher risk for developing hepatosplenic T-cell lymphoma
|-
! align="center" style="background:#DCDCDC;" + |Enteropathy-type intestinal T-cell lymphoma
[30][31][32]
| align="left" style="background:#F5F5F5;" + |
- Mature T-cell lymphoma
| align="left" style="background:#F5F5F5;" + |
| align="center" style="background:#F5F5F5;" + | + | align="center" style="background:#F5F5F5;" + | + | align="center" style="background:#F5F5F5;" + | + | align="left" style="background:#F5F5F5;" + |Painless swelling in the :
| align="left" style="background:#F5F5F5;" + |
| align="left" style="background:#F5F5F5;" + |
| align="left" style="background:#F5F5F5;" + |
- Lymphomatous infiltrate with neoplastic large cells
- May have pleomorphic, multinucleated cells
- Adjacent mucosa shows villous atrophy, crypt hyperplasia, increased inflammatory cells
- Lymphocytosis
| align="left" style="background:#F5F5F5;" + |
- Mostly diagnosed in the small intestine
|-
! align="center" style="background:#DCDCDC;" + |Extranodal T-cell lymphoma, nasal type
[33][34][35]
| align="left" style="background:#F5F5F5;" + |
- Mature T-cell lymphoma
| align="left" style="background:#F5F5F5;" + |
| align="center" style="background:#F5F5F5;" + | + | align="center" style="background:#F5F5F5;" + | - | align="center" style="background:#F5F5F5;" + | - | align="left" style="background:#F5F5F5;" + |Painless swelling in :
| align="left" style="background:#F5F5F5;" + |
| align="left" style="background:#F5F5F5;" + |
- Cytoplasmic CD3 epsilon
- Granzyme B
- Perforin
- CD2
- CD56
| align="left" style="background:#F5F5F5;" + |
- Medium sized tumor cells and polymorphic infiltrate of non-neoplastic inflammatory cells
- Lymphoma cells may be admixed with a polymorphic infiltrate of non-neoplastic inflammatory cells
| align="left" style="background:#F5F5F5;" + |
- Protrusion of eye
- Swelling of the face
- Discharge from the nose
- Nose bleeds
- Blockage of the nasal passages
|-
! align="center" style="background:#DCDCDC;" + |Angioimmunoblastic T-cell lymphoma
[36][37][38]
| align="left" style="background:#F5F5F5;" + |
- Mature T-cell lymphoma
| align="left" style="background:#F5F5F5;" + |
| align="center" style="background:#F5F5F5;" + | + | align="center" style="background:#F5F5F5;" + | + | align="center" style="background:#F5F5F5;" + | - | align="left" style="background:#F5F5F5;" + |
| align="left" style="background:#F5F5F5;" + |
- Skin rash
- abdominal pain
- bone pain
- dark urine
- shortness of breath
- chronic pain and swelling of joints
- Chest pain
| align="left" style="background:#F5F5F5;" + |
| align="left" style="background:#F5F5F5;" + |
- Leukocytic infiltrate, represented mostly by elongated cells with marked artifactual changes
- Hyperplastic germinal centers and Reed-Sternberg cells
| align="left" style="background:#F5F5F5;" + |
|-
! align="center" style="background:#DCDCDC;" + |Peripheral T-cell lymphoma, unspecified
[39][40]
| align="left" style="background:#F5F5F5;" + |
- Mature T-cell lymphoma
| align="left" style="background:#F5F5F5;" + |
- Fatigue
- Fever
- Frequent infections
| align="center" style="background:#F5F5F5;" + | - | align="center" style="background:#F5F5F5;" + | + | align="center" style="background:#F5F5F5;" + | - | align="left" style="background:#F5F5F5;" + |
| align="left" style="background:#F5F5F5;" + |
- Lymphadenopathy (swollen )
- Thirst
- Nausea
- Vomiting
- Skin and bone abnormalities
- Enlarged liver and/or spleen
| align="left" style="background:#F5F5F5;" + |
| align="left" style="background:#F5F5F5;" + |
- Clear cytoplasm, resemble Reed-Sternberg cells, with irregular, pleomorphic, hyperchromatic or nuclei
- A lot of mitotic figures; very broad cytologic spectrum
| align="left" style="background:#F5F5F5;" + |
- Endogenous immunosupression
- Patients may present with p.jiroveci or varicella zoster infection
- Can be confused with other infectious or rheumatologic diseases
|}
Epidemiology and Demographics
- The incidence of hepatosplenic t cell lymphoma is 0.3 per 100000 individuals per year.
- It occurs in younger group of patients, most cases falling in 20-40 years of age group.
- Men are more affected than the females.
Risk Factors
Common risk factors include:
- Autoimmune diseases
- Patients on immunosuppresant medications.
- Patients on chemotherapy.
- Inflammatory bowel disease
- Organ transplant patients.
Screening
There is insufficient evidence to recommend routine screening for hepatosplenic t cell lymphoma.
Natural History, Complications, and Prognosis
Natural history
- Patients have a history of immunosupression such as inflammatory bowel disease under treatment or organ transplant.[41]
- The mean age group is 35 years and most of the patients are males.
- Initial symptoms are fever, weight loss, night sweats and then progress to more severe symptoms depending on the organ involvement but there is no lymphadenopathy.
- Patients also present with symptoms of liver, spleen and bone marrow dysfunction.
- If left untreated, patients can develop liver failure, pancytopenia, or spleen rupture.
Complications
- Hepatomegaly
- Hepatic failure
- Portal vein thrombosis
- Splenomegaly
- Splenic infarction
- Spleen rupture
- Splenic vein thrombosis
- Anemia
- Thrombocytopenia
- Neutropenia
- Neurological dysfunction if metastasizes to brain.
- Intestinal perforation
- Intestinal obstruction
Prognosis
- The prognosis is very poor, with patients dying within 2-3 years of diagnosis even after recieving treatment[42].
Diagnosis
Diagnostic Study of Choice
- Biopsy of the tumor is the gold standard diagnostic test for diagnosing hepatosplenic t cell lymphoma[43].
- CT scan and PET scan are used to assess the spread of the lymphoma.
Symptoms
The most common symtoms are[44]:
- Fever
- Weight loss
- Night sweats
- Pain abdomen
- Jaundice
- Fatigue
- Recurrent infections
- Bleeding
Physical Examination
Temperature
- Fever is often present
Skin
Thorax
- Pleural effusion
- Chest tenderness
Abdomen
- Splenomegaly
- Hepatomegaly
- Ascites
- Abdomen tenderness[41]
Extremities
- Bone tenderness[41]
Laboratory Findings
- Biopsy of the tumor:
- Histology - small-to intermediate sized T lymphocytes infiltrate the sinusoids of the liver and the splenic red pulp.
- Flow cytometry and immunophenotyping - The lymphoma cells are typically CD2+, CD3+, CD4−, CD5−, CD7+, CD8− CD42+, CD52+, CD76+, CD82+ with either gamma-delta or alpha-beta T-cell phenotypic receptor expression[45].
- Karyotyping - Isochromosome of the long arm of chromosome 7 is a genetic abnormality described in hepatosplenic t cell lymphoma. It could also be in association with trisomy 8 and a loss of a sex chromosome[46].
- Bone marrow biopsy; The bone marrow is characterized by neoplastic cells in the sinusoids.
- Complete blood count; Pancytopenia
- Liver function tests: Deranged LFT
- Elevated transaminases
- Hyperbilirubinemia
- Hypoproteinemia
- Elevated alkaline phosphatase
- Elevated PT/INR
Electrocardiogram
There are no ECG findings associated with hepatosplenic t cell lymphoma.
X-ray
There are no x-ray findings associated with hepatosplenic t cell lymphoma but pleural effusion might be present.
Echocardiography or Ultrasound
- There are no echocardiography findings associated with hepatosplenic t cell lymphoma.
- On ultrasound of abdomen:
CT scan
Tumor mass can be seen in liver or spleen or both.
MRI
Tumor mass can be seen in liver or spleen or both.
Other Imaging Findings
PET scan: On PET scan, tumor mass can be seen in liver or spleen or if it has metastatsized to any other organ.
Treatment
Medical Therapy
- Induction therapy[47]
- Consolidation therapy
- Radiation therapy
- Allogenic bone marrow transplant[48]
- Autologous bone marrow transplant
- Additional medications given during chemotherapy
Surgery
Surgical intervention is not recommended for the management of hepaosplenic t cell lymphoma.
Primary Prevention
There are no established measures for the primary prevention of hepatosplenic t cell lymphoma.
Secondary Prevention
There are no established measures for the secondary prevention of hepatosplenic t cell lymphoma.
References
- ↑ Armitage JO (2017). "The aggressive peripheral T-cell lymphomas: 2017". Am J Hematol. 92 (7): 706–715. doi:10.1002/ajh.24791. PMID 28516671.
- ↑ Brandt PH, Rahmat LT, Ali SS (2019). "A rare case of hepatosplenic gamma-delta T-cell lymphoma and secondary hemophagocytic lymphohistiocytosis". Clin Case Rep. 7 (1): 164–169. doi:10.1002/ccr3.1924. PMC 6333078. PMID 30656034.
- ↑ Choi Y, Jeon SY, Yoo WH (2018). "Hepatosplenic T-Cell Lymphoma Arising in a Patient Treated With Tumor Necrosis Factor-α Inhibitors for Ankylosing Spondylitis". J Clin Rheumatol. doi:10.1097/RHU.0000000000000805. PMID 29933321.
- ↑ Gowda L, Foss F (2019). "Hepatosplenic T-Cell Lymphomas". Cancer Treat Res. 176: 185–193. doi:10.1007/978-3-319-99716-2_9. PMID 30596219.
- ↑ Gaulard P, Bourquelot P, Kanavaros P, Haioun C, Le Couedic JP, Divine M; et al. (1990). "Expression of the alpha/beta and gamma/delta T-cell receptors in 57 cases of peripheral T-cell lymphomas. Identification of a subset of gamma/delta T-cell lymphomas". Am J Pathol. 137 (3): 617–28. PMC 1877506. PMID 1698028.
- ↑ Yabe M, Miranda RN, Medeiros LJ (2018). "Hepatosplenic T-cell Lymphoma: a review of clinicopathologic features, pathogenesis, and prognostic factors". Hum Pathol. 74: 5–16. doi:10.1016/j.humpath.2018.01.005. PMID 29337025.
- ↑ Gallamini A, Stelitano C, Calvi R, Bellei M, Mattei D, Vitolo U; et al. (2004). "Peripheral T-cell lymphoma unspecified (PTCL-U): a new prognostic model from a retrospective multicentric clinical study". Blood. 103 (7): 2474–9. doi:10.1182/blood-2003-09-3080. PMID 14645001.
- ↑ Shelly D, Gujral S (2017). "Early T-Cell Precursor Acute Lymphoblastic Leukaemia/Lymphoma: Immunohistochemical Evaluation of Four Lymph Node Biopsies". J Clin Diagn Res. 11 (7): EL01–EL02. doi:10.7860/JCDR/2017/29352.10164. PMC 5583929. PMID 28892922.
- ↑ You MJ, Medeiros LJ, Hsi ED (2015). "T-lymphoblastic leukemia/lymphoma". Am J Clin Pathol. 144 (3): 411–22. doi:10.1309/AJCPMF03LVSBLHPJ. PMID 26276771.
- ↑ Rose, M. G. (2004). "T-Cell Large Granular Lymphocyte Leukemia and Related Disorders". The Oncologist. 9 (3): 247–258. doi:10.1634/theoncologist.9-3-247. ISSN 1083-7159.
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