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Marginal zone lymphomas (MZLs) are a heterogeneous group of neoplasms that resemble the normal B-cell populations of the marginal zone of a lymph node. It includes three different subtypes, nodal, splenic, and extra -nodal, each, with overlapping features and yet unique characteristics. Nodal Marginal Zone lymphoma (NMZL) accounts for only 1% of all Non-Hodgkin Lymphoma (NHL). Marginal Zone lymphoma with plasmacytic differentiation is not very common. We report a unique case of Nodal marginal zone lymphoma initially presenting with lymphocytosis and lymphadenopathy, work up indicating low grade lymphoma, subsequently developing hyper viscosity syndrome due to symptomatic IgM monoclonal gammopathy. A 68 year old female was noted to have persistent leukocytosis with lymphocytic predominance after completing treatment for a urinary tract infection. Clinical exam revealed bilateral axillary adenopathy. CT scan of neck, chest, abdomen and pelvis revealed axillary, mediastinal and retroperitoneal adenopathy with splenomegaly. Chronic lymphocytic leukemia (CLL) was suspected and work up initiated. Peripheral blood Flow-cytometry revealed 24% small B-cells with surface kappa light chain restriction consistent with mature B-cell lymphoma or leukemia without typical immune phenotype of CLL. Lab reported significant elevation of total protein at 10 g/dl. Workup for para-proteinemia consistent with IgM level over 5000 mg/dl, with serum viscosity of 8. Axillary lymph node excisional biopsy reported marginal zone lymphoma with plasmacytic differentiation. Bone marrow biopsy demonstrated 42% monoclonal B-cells without co-expression of CD5 and CD23. FISH studies positive for duplication 1q and Molecular testing negative for MYDD88 mutation. Decision was made to initiate chemo therapy with R-CVP for a total of six cycles. Her treatment course was complicated by symptomatic hyper viscosity syndrome necessitating therapeutic plasmapheresis. Patient successfully completed chemo immunotherapy with normalization of blood counts, resolution of palpable adenopathy and splenomegaly. Nodal marginal lymphoma (NMZL) originates from nodal mono-cytoid or marginal zone B cells and the pathogenesis usually involves acquired mutations in oncogenes and tumor suppressor genes involving MLL2, PTTPRD, NOTCH2, and KLF2 genes. The median age is round 70 years with slight male predominance. The clinical picture varies and usually includes generalized lymphadenopathy along with B symptoms and infrequently with mild monoclonal gammopathy (any immunoglobulin subtype-IgM uncommon). Marginal Zone lymphoma with plasmacytic differentiation is not as common and shares immuno-histochemical features with lympho-plasmacytic lymphoma (LPL). They both express B cell markers CD19, CD20, and CD22) and not CD5, CD10 or CD23. Clinically, NMZL is more likely to present with prominent lymphadenopathy, while LPL can exclusively affect the marrow without extramedullary involvement. IgM levels in NMZL tend to be lower than in LPL, typically lower than 1000 mg/d. MYD88 mutation is very common in LPL, and can be seen in 10-15% NMZL. The presence of IgM monoclonal gammopathy increases the serum viscosity which can lead to serious neurologic and ophthalmologic complications. Treatment involves emergent plasmapheresis. Our case highlights a less common NHL, presenting with significant paraproteinemia and developing hyper viscosity syndrome with impressive response to plasmapheresis and chemo immunotherapy.

Marginal zone B-cell lymphomas (MZBL) constitute 7% of all non-Hodgkin lymphomas, being the third most common subtype after diffuse large B-cell lymphoma(DLBCL) and follicular lymphoma. Extranodal MZBL (ENMZBL) most commonly arise from the mucosa-associated lymphoid tissue (MALT lymphoma), with stomach being the most common site. ENMZBL involving the dura is anatomically unusual and very rare. A 54 year old female presented to the hospital with worsening headaches and new onset generalized tonic clonic seizures. Complete blood counts and chemistry were unremarkable. No constitutional symptoms, new / progressive lymphadenopathy reported. Magnetic resonance Imaging( MRI) brain showed an enhancing right subdural soft tissue lesion overlying the right frontotemporal lobe suggestive of meningioma versus metastasis. Computed Tomography (CT) chest/abdomen/pelvis revealed no mass or lymphadenopathy. Lumbar Puncture cerebrospinal fluid cytology was negative for malignancy. She underwent brain biopsy. Pathology revealed diffuse infiltrate of small to medium-sized lymphoid cells, Immunohistochemical stains positive for CD 20, PAX5, CD 79a, Ki-67 at 5-10%, weakly positive for MUM1 and BCL2, negative for CD3, CD5, CD10, BCL6, cyclin D1, consistent with ENMZBL. Bone marrow biopsy and aspiration negative for involvement with lymphoma. Patient received local/regional therapy with radiation (XRT), total dose 24 Gy in 12 fractions. She presented six months later with worsening neck pain. MRI cervical spine revealed diffuse thick dural based enhancement within the spinal canal at C1-C4 levels leading to moderate-to-severe spinal canal stenosis at C2-C3 level with significant soft tissue extension. Repeat labs, systemic imaging, and bone marrow biopsy continued to show no evidence of systemic disease. She received low dose XRT to the entire craniospinal axis (dose-4Gy). Patient developed profound pancytopenia secondary to craniospinal XRT. After count recovery she initiated daily oral Ibrutinib (560 mg) with plans for a treatment duration of one year. Dural based ENMZL usually present as solitary masses, mimicking meningioma's. Marked female predilection is seen with median age of onset 50 years. Very few cases have been reported in literature with no standard therapy being described. ENMZL are usually indolent requiring less aggressive therapy. In contrast, primary CNS lymphoma (PCNSL) of diffuse large B cell histology is usually aggressive with high tendency to relapse, requiring treatment with high dose methotrexate based regimes. Dural based ENMZL therapy entails local treatments such as surgery and radiation therapy (relatively low dose radiation usually effective with prolonged durable responses). Systemic treatment with single agent Rituximab or with Tyrosine Kinase inhibitors like Ibrutinib with CNS penetration can also be considered. Long-term follow-up is recommended even in those patients who achieved complete remission as relapses may occur.

Marginal zone (MZ) lymphomas (MZLs) represent a group of lymphomas originating from B lymphocytes of the “marginal zone” which is the external part of the secondary lymphoid follicles. The WHO classifies MZL into 3 entities; extranodal MZL, splenic MZL and nodal MZL. Extranodal marginal zone lymphoma (EMZL) can arise in different tissues, including the stomach, salivary gland, lung, small bowel, thyroid, ocular adnexa and skin. We present a 25 years old female with a history of angioedema and chronic cutaneous eczema who developed an unusual EMZL. Patient presented with a history of rapidly enlarging skin nodule on her left elbow that had been present for almost one year. Over a period of 2-3 weeks she felt the nodule rapidly changed in size and shape. Excisional biopsy of the mass revealed a lymphoid infiltrate based in the reticular dermis and focally extending into the subcutaneous adipose tissue with formation of disrupted lymphoid follicles positive for CD20, CD23 and BCL2 but negative for CD10, Cyclin D1 and SOX11. Diagnosis was consistent with extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma). Patient on presentation did not have any B symptoms other cutaneous lesions, lymphadenopathy or hepatosplenomegaly. PET scan revealed no evidence of abnormal uptake leading to a final Stage IE definition. Patient initiated definitive radiation therapy. EMZL accounts for 5 -10 % of non-Hodgkin lymphoma. It has been described often in organs that are normally devoid of germinal centers. It may arise in reactive lymphoid tissue induced by chronic inflammation in extranodal sites. Primary cutaneous marginal zone lymphoma (PCMZL) is associated with infectious etiologies such as Borrelia burgdorferi and less commonly with viral infections or in relation to autoimmune disorders. Autoimmune disorders, specifically Sjögren's syndrome is associated with a 30-fold increased risk of marginal zone lymphoma. Localized disease can be treated by local radiotherapy, intralesional injections or excision. Widespread skin disease is usually treated with a CD20 directed monoclonal antibody-Rituximab. Patients with PCMZL usually have an indolent clinical course. Extracutaneous dissemination of MALT Lymphoma is uncommon and happens in 6-8 % of patients. The 5 years overall survival is between 98-100%. Family physicians and dermatologists should have a high index of suspicion for this rare lymphoma subtype especially in patients with inflammatory chronic skin conditions and atopy.

La délétion du chromosome 7q est l'anomalie cytogénétique la plus caractéristique du lymphome de la zone marginale splénique (LZMS). Une étude par hybridation génomique comparative de haute résolution a été conduite sur une série de 27 échantillons de LZMS afin de détecter des micro-remaniements du chromosome 7q. Une région commune de délétion (RCD) de 10,6 Mb a été délimitée sur le chromosome 7q. De plus, une microdélétion somatique du gène AHCYL2 (S-adenosyl-homocystéine hydrolase-like 2) a été détectée au sein de la RCD, définissant la plus petite RCD connue sur le chromosome 7q32 dans le SMZL et l'anomalie la plus fréquente de notre série (10/27, 37%). Bien que le séquençage du gène AHCYL2 n'a pas mis en évidence de mutation somatique, la délétion monoallélique du gène AHCYL2 est corrélée à la sous-expression de transcrits du gène AHCYL2 indiquant une haplo-insuffisance. La fonction précise de AHCYL2 reste inconnue, mais certaines données suggèrent que les protéines de type AHCYL peuvent réguler l'activité de l'enzyme AHCY (Sadénosyl- homocystéine hydrolase) et par conséquent affecter les mécanismes de transméthylation. En outre, nous avons identifié, pour la première fois dans le LZMS, une mutation R882H du gène DNMT3A (1/27, 3,7%) impliqué également dans les processus de méthylation. Ces résultats suggèrent que la dérégulation des voies métaboliques impliquées dans la méthylation peut jouer un rôle crucial dans la pathogenèse du LZMS / The chromosome 7q deletion is the most characteristic alteration in splenic marginal zone lymphoma (SMZL). High-resolution genome-focused approach was performed on 27 SMZL samples to identify submicroscopic genetic alterations on chromosome 7q. A 10.6 Mb-length common deleted region (CDR) of chromosome 7q was precisely delineated and a somatic microdeletion of the S-adenosyl-homocysteine hydrolase-like 2 (AHCYL2) gene was further detected within the CDR, defining the most frequent finding in this series (10/27, 37%) and the smallest CDR on chromosome 7q32. Although the sequencing of AHCYL2 gene did not show any evidence of somatic mutation, the monoallelic AHCYL2 gene deletion was directly correlated with underexpression of AHCYL2 transcripts, indicating a typical pattern of haploinsufficiency. The precise role of AHCYL2 remains unknown, but some data suggest that the AHCY-like proteins may regulate the activity of AHCY (S adenosylhomocysteine hydrolase) and consequently may affect the methylation metabolism. In addition, we report on a DNMT3A-R882H mutation (1/27, 3.7%) for the first time in SMZL. These findings suggest that methylation pathway dysfunction may play a crucial role in the pathogenesis of SMZL