Solitary plasmacytoma associated with Epstein-Barr virus: a clinicopathologic, cytogenetic study and literature review

    Solitary plasmacytoma associated with Epstein–Barr virus: a clinicopathological, cytogenetic study and literature review Jiaqi Yan, Jianchao Wang, Wenyan Zhang, Min Chen, Jie Chen, Weiping Liu PII: DOI: Reference:

S1092-9134(16)30205-2 doi: 10.1016/j.anndiagpath.2016.09.002 YADPA 51104

To appear in:

Annals of Diagnostic Pathology

Please cite this article as: Yan Jiaqi, Wang Jianchao, Zhang Wenyan, Chen Min, Chen Jie, Liu Weiping, Solitary plasmacytoma associated with Epstein–Barr virus: a clinicopathological, cytogenetic study and literature review, Annals of Diagnostic Pathology (2016), doi: 10.1016/j.anndiagpath.2016.09.002

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ACCEPTED MANUSCRIPT Solitary plasmacytoma associated with Epstein-Barr virus: a

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clinicopathological, cytogenetic study and literature review

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Jiaqi Yan, Jianchao Wang, Wenyan Zhang, Min Chen, Jie Chen, Weiping Liu*

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Xiang, Chengdu, Sichuan, 610041, China

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Department of Pathology, West China Hospital, Sichuan University, No.37 Guo Xue

* Corresponding authors:

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Weiping Liu

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Department of Pathology, West China Hospital, Sichuan University

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No.37 Guo Xue Xiang

China

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Chengdu, Sichuan, 610041

Tel: +86-28-85422699; Cell: +8618980601641; Fax: +86-28-85422699

E-mail: [email protected]

ACCEPTED MANUSCRIPT Abstract Solitary plasmacytoma (SP) is an uncommon, indolent tumor of plasma cell

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neoplasms that presents as a mass lesion in extramedullary sites. Evidence of Epstein-Barr virus (EBV) infection is frequently associated with various lymphatic

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and hematopoietic malignancies but is relatively rare in SP. Moreover, it is essential to distinguish EBV-positive plasmacytoma from plasmablastic lymphoma (PBL). In

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this study, we found four EBV-encoded RNA (EBER)-positive patients among fourty-six consecutive immunocompetent patients of SP and compared the clinicopathologic features of these patients to those of the EBER-negative cohort. In

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the four EBER-positive patients, the common presenting feature was a local mass

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lesion without symptoms of chronic active EBV infection. Upon histological examination, neoplastic cells demonstrated well-differentiated morphology in the

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absence of PBL components. Fluorescence in situ hybridization analysis showed that

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all cases were negative for del13q14, t(11;14)(q13;32) and MYC rearrangement but that one case had cytogenetic aberrations involving del17p13. Follow-up data revealed that EBER-positive patients had benign prognoses without aggressive clinical course and that there was no significant difference in the overall survival time between the two groups but EBER-positive patients were more likely to have disease progression(relapse/progression to multiple myeloma) compared to EBER-negative patients. More cases studies are needed to better understand the impact of EBV on disease pathogenesis and development in immunocompetent patients of SP. Key words: Solitary plasmacytoma, Epstein-Barr virus, cytogenetic analysis

ACCEPTED MANUSCRIPT Introduction Plasmacytoma is a malignant tumor that consists of a monoclonal proliferation of

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plasma cells that are derived from mature, terminally differentiated B-cells. It presents either as a single mass lesion originating in the bones or extramedullary tissues

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without bone marrow involvement (solitary plasmacytoma) or as multiple lesions localized in bone marrow (multiple myeloma). Solitary plasmacytoma (SP) is an

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uncommon type which accounts for 5% to 10% of all plasma cell malignancies [1-3]. The osseous sites of SP primarily involve the vertebrae, while the non-osseous sites of SP mainly involve the upper respiratory tract, especially the nasal cavity and sinuses.

Histologically,

SP

is

composed

of

monomorphic,

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paranasal

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well-differentiated or atypical neoplastic plasma cells that are indistinguishable from plasmablastic lymphoma (PBL). PBL is a high-grade malignant B-cell neoplasm

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that frequently develops in immunodeficient patients. Epstein-Barr virus (EBV)

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infection occurs in 60% to 75% of PBL patients, but SP is rarely associated with EBV infection. Immunodeficient patients, such as those with an HIV infection and those undergoing immunosuppressive drug therapies or transplantation, have a slightly increased risk of developing EBV-associated plasmacytomas. Based on a review of the literature, only 14 cases of EBER＋ SPs in immunocompetent patients have been reported to date [4-11]. In this study, we investigated 46 SPs in immunocompetent patients and found four new cases of tumors associated with EBV. We described the four EBER＋ patients and compared the clinicopathologic, immunophenotypic and cytogenetic characteristics of the tumors between the EBER＋ patients and the EBER

ACCEPTED MANUSCRIPT － patients. In addition, it is important to pay attention when making the differential diagnosis of PBL and EBER-positive SP.

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Materials and Methods

Forty-six cases of SPs were collected from the Department of Pathology, West

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China Hospital of Sichuan University between June 2008 and September 2015. A histologic diagnosis of each tumor was made according to the criteria set by the

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World Health Organization (WHO) classification for tumors of hematopoietic and lymphoid tissues (2008) [12]. The diagnostic criteria used were as follows [13]: (1) cases diagnosed as plasma cell neoplasm by biopsy; (2) bone marrow biopsy with <5%

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clonal plasma cells; (3) a normal skeletal survey and no lesions in the spine as

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detected using magnetic resonance imaging (MRI); (4) little or no serum/urine M band on a gel electrophoresis separation of proteins (level of >20 g/L indicates

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multiple myeloma); (5) no anemia, hypercalcemia, or renal involvement was

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attributed to the plasma cell dyscrasia; and (6) no previous immunosuppressive therapy, organ transplantation, or history or evidence of HIV-infection. The medical records for the patients were available from the hospital information system and telephone follow-ups. H&E stained sections of the tumors were used to assess their histopathologic features. We graded plasmacytomas according to the histological grading criteria described

by

Bartl

et

al

[14].

The

EnVision

method

was

used

for

immunohistochemistry with the following antibodies: CD138 (MI15, GeneTech, USA), CD20 (L26, Dako, Denmark), CD79a (JCB117, Dako, Denmark), PC (VS38C,

ACCEPTED MANUSCRIPT Dako, Denmark), Mum-1 (MUM1p, Dako, Denmark), CD56 (123, C3; Zymed, South San Francisco, CA), CyclinD1 (SP4, Thermo, USA), Ki-67 (MIB-1, Maixin, China),

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kappa and lambda immunoglobulin (Ig) light chains (polyclonal, NeoMarker, USA). Diaminobenzidine (DAB) was used as a substrate, and positive staining was dark

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brown.

In situ hybridization was performed using a digoxin-labeled oligonucleotide probe

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complementary to 2 EBV-encoded small RNAs, EBER-1 and EBER-2, (EBER1/2; Dako, NO.Y520001). Rabbit anti-digoxin antibody conjugated with horseradish peroxidase (Dako) was used to detect the probe. The dark brown hybridizing signal

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was located in the cell nuclei. The number of positive cells was visually estimated at

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<1 (single-), 1 to 25 (scatter-), 25 to 100 (cluster-) and >100 (diffuse-) per medium power field (mpf) using a 10X ocular lens and a 20X objective. Cases in which the

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positive reaction presented as a cluster- or diffuse-type was regarded as an

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EBV-positive lymphoma [15]. Fluorescence in situ hybridization (FISH) was performed using formalin-fixed, paraffin-embedded tissue sections. Four probes were used: the LSI c-Myc Dual Color Break Apart Rearrangement probe, which hybridizes to band 8q24, and the presence of IGH translocations with CCND1 (11q13) was studied with the dual color translocation probe LSI IGH/CCND1. The LSI Rb1 SpectrumOrange probe mapping at 13q14 was used to test for 13q deletions. The LSI TP53 SpectrumOrange probe mapping at 17p13 was used to test for 17p deletions (Abbott Diagnostics, Chicago, IL, USA). All probes were used according to the manufacturer’s recommendation. A total

ACCEPTED MANUSCRIPT of 200 non-overlapping nuclei were scored; the cut-off for del13q and del17p was conservatively set at 40%. The threshold of positivity was defined as >15.5% for

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c-Myc, and the cut-off values for the translocation dual fusion probe IGH/CCND1 ranged from 10.8 to 20.1% [16].

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Overall survival time was calculated from the date of diagnosis to the date of death or last follow-up. Survival data were assessed using the long-rank test. Fisher's exact

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test was used for the determination of significant differences of clinical, immunophenotypic and cytogenetic characteristics. A p-value of <0.05 was considered statistically significant. All statistical analyses were performed using SPSS

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software for Windows, version 22.0.

ACCEPTED MANUSCRIPT RESULTS Clinical features

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A total of 46 cases were identified. None of the patients had been treated with immunosuppressive therapy, had undergone organ transplantation, or had a history or

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evidence of HIV-infection. EBER was positive in 4 patients(4/46, 8.7%). The clinical features of the EBER＋ and EBER－ patients are summarized in Table 1 and Table

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2. The EBER＋ cohort had a median age of 44 years (range 21-67 years) and consisted of 3 (75%) men and 1 (25%) woman. The average clinical history was 6.5 months. The sites of the neoplasms included the nasal cavity, skull, clavicle, and

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humerus. The clinical manifestations of patient 1 were closely related to the anatomic

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sites involved, and the symptoms were nasal obstruction, rhinorrhea and epistaxis. Patient 2 presented with localized, painless masses. Patient 3 and patient 4

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complained mainly of pain and enlarged masses. The sizes of their tumors ranged

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from 3.5×3×3 cm to 10×3×2 cm. Laboratory data and results of the auxiliary examination given at the time of diagnosis are summarized in Table 2. Patient 1 had mild anemia and hypocalcemia. Serum lactate dehydrogenase, β2-microglobulin, and creatinine levels were all within the normal range in the remaining 3 patients. There was no evidence of an M-protein component in 2 patients, but we detected Bence-Jones protein in patient 2 and serum M-protein (IgG, 19.8 g/L and κ light chain) in patient 4. Bone imaging showed 3 patients with adjacent bone destruction. Bone marrow biopsies were performed in these patients, and all of them showed negative results. In order to have a negative diagnosis, the bone marrow clonal plasma cell

ACCEPTED MANUSCRIPT infiltration must be less than 5% of all nucleated cells. In addition, the four patients did not have symptoms of chronic, active EBV infection, such as fever,

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hepatosplenomegaly, liver function abnormalities or monocytosis. There was no difference in age, gender, tumor site, M-component or osteolytic destruction between

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the EBER＋ and EBER－ patients (p>0.05). Histopathologic findings

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Histopathological examination showed that all 46 cases had a diffuse growth pattern and that the normal tissues had been replaced entirely by neoplastic plasma cells. Based on Bartl’s histological grading criteria, 37 cases in the EBER＋group

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presented as well-differentiated (Grade I and II) and 5 cases were classified as having

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plasmablastic features (Grade III). In the EBER＋ group, case 1 and case 4 were classified as Grade I. The neoplastic cells were composed of mature, differentiated

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plasma cells, with eccentric cartwheel nuclei, a perinuclear hof and basophilic

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cytoplasm. Nucleoli were usually inconspicuous, and mitotic figures were observed occasionally (Figure 1). Case 2 and Case 3 were classified as Grade II. The tumor tissues were intermingled with well differentiated plasma cells and anaplastic cells, and at least 50% of the tumor cells showed irregular nuclear contours. The cytoplasmic/nuclear ratio was low, and a perinuclear hof was usually observed. Russell’s bodies and coagulative necrosis were observed in Case 4. Deposition of amyloid materials was found in all cases except Case 1. Occasional tumor giant cells were identified in Case 2. “Blood lakes” were observed in 3 cases. There was no evidence of a “starry sky” pattern in any of the four EBV-positive cases. There were

ACCEPTED MANUSCRIPT no statistically significant differences in the cytomorphologic features between EBER

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Immunophenotype, cytogenetic features and EBV status

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＋ and EBER－ cases.

The results of immunohistochemical and cytogenetic studies on the 46 patients are

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listed in Table 3. The neoplastic cells were all positive for Mum-1, whereas none of the cases were positive for CD20. The great majority of tumors expressed Mum-1, PC

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and CD138. Expression of CD79a, CD56 and CyclinD1 was noted in 34 of 46 (73.9%), 13 of 46 (28.2%), and 8 of 16 (50%) tumors, respectively. The EBER＋ tumors were all positive for CD138, Mum-1 and monotypic cytoplasmic light chain

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(lambda). Cases 2 and 4 were positive for CD56. Only Case 3 expressed cyclin D1.

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The median Ki-67 proliferation index was 25% (range 5-40%) in the EBER＋ tumors, while in EBER－ tumors it was 24.6% (range 1-80%). In situ hybridization analysis

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for EBV-encoded RNA (EBER) showed that the neoplastic cells were diffusely

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positive in all four cases. FISH analysis was successfully performed in 37 cases, and the results are summarized in Table 3. Chromosomal abnormalities were found in 14 cases (37.8%). One cytogenetic aberration was found in 10 cases, and two cytogenetic aberrations were detected in 4 cases. Loss of chromosome region 13q14 was identified in 10 cases (27.0%), t(11;14)(q13;q32) was detected in four cases (10.8%), 5 cases (13.5%) showed a 17p deletion, and one case showed a break of c-Myc. Of the 4 patients who harbored two cytogenetic aberrations, two had t(11; 14)(q13;q32)/del13q14 and two had del13q14/del17p13 simultaneously. In EBER＋ patients, del(17p13) was found in 1 of 4 cases(75%, cases 4), in contrast with 4 of 33

ACCEPTED MANUSCRIPT cases (12.1%) in the EBER－ group. All of the EBER＋ patients were negative for del13q14, t(11; 14)(q13;q32) and MYC rearrangement.

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Treatment and follow-up

Clinical treatment information was collected for 46 patients, and most of the

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patients (31/46, 67.3%) underwent surgical treatment. The treatment and outcome of the EBER＋ patients were summarized in Table 2. Patients were treated with

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different therapeutic methods. Patient 1 and patient 4 were treated with resection and radiation therapy (total dose 50 Gy/25 fractions), patient 2 was treated with surgery and chemotherapy (doxorubicin, dexamethasone, thalidomide), and patient 3 received

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a surgical excision only. Follow-up data were available for 38/46 (82.6%) patients.

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The median period of follow-up was 33 months (range10-83 months). The 3-year survival in EBER＋ and EBER－ patients was 75% and 68.7%, respectively. A

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Kaplan-Meier analysis revealed that there was no significant difference in the overall

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survival (OS) time between the two groups (p>0.05). Patient 1 was alive and free of disease for 70 months. Patient 2 progressed to multiple myeloma within 3 years and died of the disease at 55 months. Patient 3 and patient 4 had recurrence within 19 and 24 months, respectively, and they were alive with disease at the last follow-up. Compared with the EBER＋ patients, the EBER＋ patients had higher risks of disease progression (p=0.035).

Discussion

ACCEPTED MANUSCRIPT EBV belongs to the r-DNA herpes virus family and was the first discovered virus associated with lymphomas. Numerous studies have found that EBV infection is

lymphoma,

extranodal

NK/T-cell

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related to the occurrence of a variety of lymphoid proliferations such as Burkitt’s lymphoma,

and

nasal-type

and

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immunodeficiency-associated lymphoproliferative disorders [17]. The virus is lymphotropic and is capable of causing nonproductive (latent) and productive (lytic)

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infections in lymphocytes and can stimulate cell proliferation and transformation. In B-cells, latent EBV infection can cause polyclonal B-cell proliferation and eventual monoclonal malignant transformation. EBV-positive plasmacytomas are usually

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secondary to HIV-infection, organ transplantation and immunosuppressive treatment.

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According to published clinical studies, SP patients with immunocompetent status are rarely associated with EBV; only 14 cases have been reported so far [4-11]. At our

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hospital, only 8.7% of all confirmed SPs (4/46) were associated with EBV between

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2008 and 2015. Including the four cases we reported, a total of 18 cases of EBV-positive immunocompetent SPs have been reported; they are summarized in Table 4. None of the 18 patients were treated with immunosuppressive therapy or underwent organ transplantation. The median age of the group was 53 years (range 21-90), the patients were predominantly male (12 men and 3 women), and the site of the neoplasms were most commonly in the head and neck (eight cases). Four cases were in the digestive tract, while others occurred in the penis, mediastinum, clavicle and humerus. It is suggested that the possibilities of a relationship of an SP from the head and neck region (especially the nasal cavity) and the effects of EBV should be

ACCEPTED MANUSCRIPT considered even in immunocompetent patients. Follow-up data were available for 11 patients, among which one died within 55 months and ten were alive at the last

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follow-up. The average survival time was 51.9 months (range 14.7-90 months). Almost all patients were treated with surgical excision with CT and/or RT. Although

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EBV-positive lymphoma is frequently resistant to combination therapy, 8 patients who received CT/RT achieved a complete response except one case that relapsed.

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Morphologically, most of the tumors were well differentiated (12/15, 80%), whereas 3 cases contained poorly-differentiated cells compatible with PBL. Chang et al investigated 58 plasmacytomas, including 4 EBER＋ cases, and concluded that

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plasmablastic cytomorphologic features in plasmacytomas were significantly

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associated with EBER-positivity [8]. EBV-positive SPs in poorly differentiated neoplasms should be distinguished from PBL. Because a plasmacytoma is generally

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composed of mature plasma cells, when it shows anaplastic characteristics and

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EBV-positivity, PBL is an important diagnostic consideration. PBL is known to have a high EBV infection rate. Approximately 60-75% of PBL patients are associated with an EBV infection, and a previous study has suggested that EBV positivity was of important value when the differential diagnosis is between plasmablastic plasmacytoma and PBL [18-20]. PBL often shows plasmacytoid or immunoblastic morphology with more mitotic figures than SPs. The background infiltrate frequently contains small mature lymphocytes, apoptotic bodies and tingible body macrophages that impart a ‘starry-sky’ appearance. The immunophenotype of PBL is similar to plasma cell neoplasms. It demonstrates weak or no expression of CD45 or the B-cell

ACCEPTED MANUSCRIPT markers CD20 and PAX5. The terminal B-cell differentiation markers, CD138 and Mum-1, are almost expressed [21]. CD56 is commonly expressed in HIV-positive

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PBLs, but it is usually not expressed in extramedullary plasmacytoma. The Ki-67 proliferation index is generally high in PBL patients (>70%) and >80% in more than

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60% of the tumors [22]. Research on the genetic features of PBL shows that MYC gene rearrangement is the most frequent cytogenetic abnormality detected and occurs

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in approximately 49% of cases [23]. CD138 and Mum-1 were positive in all 4 of our cases, while CD20 was negative in all 4 cases. CD56 was partially expressed in one case, and the median Ki-67 index was 25%. No MYC gene rearrangement was

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detected in the examined cases. The clinical course of PBL is aggressive; most of the

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patients are in an advanced stage (Stage II or III) by the time it is diagnosed and usually die within 1 year. Recently, from a large meta-analysis of 277 patients, the

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median survival of immunocompetent patients with EBV-positive PBL was reported

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as only 11 months [24]. An SP has a more favorable prognosis than PBL. In our cohorts, the 3-year survival rate was 75%, and only one patient died of MM after 55 months.

Because the genetic features of EBV-positive SPs are not well studied, we attempted to characterize the molecular genetic profile of this rare entity by FISH in order to compare it with known common genetic abnormalities of EBV-negative SPs. Deletions of 13q14 result in loss of the tumor suppressor gene Rb. Rb deletion leads to overexpression of cell cycle-related genes, resulting in the clonal proliferation of plasma cells. In extramedullary plasmacytomas, the incidence of 13q14 deletion was

ACCEPTED MANUSCRIPT 17%-40% [25]; our analyses found that 30.3% of the EBER－ cases had del13q14, but none of EBER＋ patients had del13q14. Although del13q14 is considered an

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adverse prognostic factor in MM, no significant correlation with survival time or relapse were identified in our groups. The deletion of the 17p13 chromosome could

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lead to the inactivation of the tumor suppressor gene p53. p53 inactivation is known to be associated with an aggressive clinical behavior in plasmacytomas, and it exists

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most commonly in patients with advanced disease. It is reported that the occurrence of del17p13 is 14-16% in extramedullary plasmacytomas [26,27]. Our data showed that 13.5% cases had this chromosome abnormality, including one EBER＋ patients.

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Poirel et al studied 35 EBV-associated post-transplantation lymphoproliferative

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disorders (PTLDs) and found that 3 cases had del17p13 [28]. However, the role of del17p13 in the development and progression of EBV-induced lymphoproliferative

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diseases remains unknown and needs further study. The t(11;14)(q13;q32)

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translocation leads to over expression of the CCND1 gene, which results in dysregulation of cell cycle progression and is thought to be a favorable or neutral prognostic factor n MMs. We identified t(11;14)(q13;q32) in 10.8% of these patients, which was similar to other reports [29], but this was absent in our EBER＋ cases. MYC is an oncogene located on 8q24, and the oncogenic activation of MYC is an important pathogenic element in various lymphoproliferative diseases. It is known to be deregulated in Burkitt’s lymphoma chromosomal translocation and in 45% of advanced MM cases, indicating that it may be an acquired alteration associated with a late progression event [30]. MYC alteration is frequently found in PBL. In addition,

ACCEPTED MANUSCRIPT MYC rearrangements occur more often in EBV-positive compared with EBV-negative PBLs. The detection of MYC status may help to distinguish intermediate- to

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low-differentiated plasmacytomas with plasmablastic transformation from PBLs. Loghavi et al reported 4 EBV+ cases that all lacked overexpression of MYC protein

in our study showed MYC rearrangement.

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and MYC gene rearrangement [4]. Consistent with their study, no EBER＋ patients

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Although EBV positivity has been associated with a more aggressive clinical course, and, in hematolymphoid malignancies, studies have shown that the survival time of SPs was less affected by EBV-infections, our study had no overall survival

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differences between the EBER＋ and EBER－ groups. A large-sample investigation

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of plasmacytomas by Dores et al reported that the 5-year survival rates of SPs ranged from approximately 70% to 80% [31]. In the reported EBER＋ cases, 69.2% were

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alive with no evidence of disease at their last follow-up (median follow-up time of 60

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months). In spite of the favorable outcome, our analysis found that EBER＋ patients had higher risks of disease progression than EBER－ patients. Patients with EBV positivity might be more prone to relapse or progression to MM. More cases and further studies are necessary to ascertain the role of EBV infection in the pathogenesis and development of the tumor.

Disclosure statement The authors have no potential conflicts of interest or financial dependence regarding

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this publication.

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Bink K, Haralambieva E, Kremer M, Ott G, Beham-Schmid C, de Leval L, et al. Primary extramedullary plasmacytoma: similarities with and differences from multiple myeloma revealed by interphase cytogenetics. Haematologica 2008;93:623-6.

ACCEPTED MANUSCRIPT 26.

Billecke L, Murga Penas EM, May AM, Engelhardt M, Nagler A, Leiba M, et al. Cytogenetics of extramedullary manifestations in multiple myeloma. Br J

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27.

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Haematol 2013;161:87-94.

Comfere NI, Gonzalez-Santiago TM, Peters MS, Knudson RA, Ketterling RP,

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Gibson LE. Cutaneous extramedullary plasmacytoma: clinical, prognostic, and interphase cytogenetic analysis. Am J Dermatopathol 2013;35:357-63. Poirel HA, Bernheim A, Schneider A, Meddeb M, Choquet S, Leblond V, et al.

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28.

Characteristic pattern of chromosomal imbalances in posttransplantation lymphoproliferative

disorders:

correlation

with

histopathological

Kojima M, Motoori T, Tamaki Y, Igarashi T, Matsumoto M, Shimizu K, et al.

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29.

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subcategories and EBV status. Transplantation 2005;80:176-84.

Cyclin D1 protein overexpression in extrameduallary plasmacytoma: a

Shou Y, Martelli ML, Gabrea A, Qi Y, Brents LA, Roschke A, et al. Diverse

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30.

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clinicopathologic study of 11 cases. J Clin Exp Hematopathol. 2009;49:53-6.

karyotypic abnormalities of the c-myc locus associated with c-myc dysregulation and tumor progression in multiple myeloma. Proc Natl Acad Sci U S A 2000;97:228–33.

31.

Dores GM, Landgren O, McGlynn KA, Curtis RE, Linet MS, Devesa SS. Plasmacytoma of bone, extramedullary plasmacytoma, and multiple myeloma: incidence and survival in the United States, 1992–2004. Br J Haematol 2009;144:86-94.

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Figure legend

Figure 1. Tumor tissue from the humerus of patient 4. (A) Tumor cells grow

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diffusely and replace the normal structure. (B) Tumor cells were composed of well-differentiated plasma cells with eccentric cartwheel nuclei that were similar to

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normal plasma cells. Russell bodies were also identified. (C) Tissue stained positive for CD138. (D) Tissue stained positive for lambda light chain. (E) The Ki67 proliferation index was ~25%. (F) Tumor cells were diffusely positive for EBER.

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(G,H) FISH showed no evidence of MYC rearrangement and deletion of 17p13.

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Cli

Present

L

β2-mi

H

Se

Ser

Siz

nic

ation

D

croglo

b

ru

um

M-co

biops

e

Thera

com

r

e(c

al

H

bulin

g

m

Crμ

mpo

y(PC

dest

py

e

site

m)

his

g/

mg/L

/

Ca

mol

nent

s,%)

T

Table 1 Clinical features of patients with EBV-positive solitary plasmacytoma

tor

L

L

m

/L

Seru

tie

/Ge

mo

nt

nder

1

27/

Na

3.5

M

sal

×3

cav

×3

y

m

m

(M

ol/

Urin

o)

L

e

nasal 12

ity

2

67/

Sk

4.5

M

ull

×4

BM

9

1.48

obstruct

1

ion,epis

1

taxis

2

Painles s mass

×4

9 5

1.9

75.

7

9

5

ion

<1%

2.1

84.

3

9

0

AN

tion+

ED,

RT

70 mon ths

neg

1

Yes

Resec

1%

ƛ

Y es

Resec

Pro

tion+

gres

ADT

sion

2

to MM

ED

8

neg

Out

ruct

neg

1.65 1

Bon

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Tu

SC

Age

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Pa

,

38/

Cla

4×

M

vic

4×

le

4

50/F

2

avicular

3

3

D at 55m onth s

supracl

2.16

neg

1

1

2.1

74.

mass,pa

4

3

3

5

in

3

1

AC

3

CE

PT

DO

5%

neg

N o

Resec

AW

tion

D, 83 mon ths

Hu

10

Mass in

2.42

IgG,

me

×3

upper

1

1

2.4

73.

Ƙ

rus

×2

limb,pa

1

2

5

9

neg

in

6

4

<1 %

Yes

Resec

AW

tion+

D,

RT

21m onth s

Abbreviations: ANED: alive with no evidence of disease; AWD: alive with relapsing disease; ADT:doxorubicin, dexamethasone, Thalidomide;DOD:Died of disease; female; FU: Follow-up; M: male; MM: multiple myeloma; RT: radiation therapy

ACCEPTED MANUSCRIPT Table 2 Clinical features of solitary plasmacytoma including EBER-positive and EBER-negative groups Contents

Total(%)

EBER-positive(%)

EBER-negative(%)

P Value

<60

25(55.6)

3(75)

22(53.6)

NS

≥60

21(44.4)

1(25)

20(47.6)

Male

31(67.3)

3(75)

Female

15(33.3)

1(25)

bone

26(57.8)

3(75)

extramedullary

20(43.4)

1(25)

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Auxiliary examination

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Type

NS

28(66.7)

NS

14(34.1)

NS

23(56.1)

NS

19(45.2)

NS

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Gender

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Age

M-protein(serum)

13(28.2)

1(25)

12(28.5)

NS

Bence-Jones(urine)

18(39.1)

1(25)

17(40.5)

NS

bone destruction

17(36.9)

3(75)

14(35.7)

NS

Dead

11(24.4)

1(25)

10(24.3)

NS

Alive

27(71.1)

3(75)

24(75.6)

NS

Relapse/progression

9(23.7)

3(75)

6(17.6)

0.035

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PT

ED

up(n=38)

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Follow

ACCEPTED MANUSCRIPT Table3 Morphology, immunophenotype and cytogenetic features of solitary plasmacytoma including EBV-positive and EBV-negative groups* Total

EBV-positive

EBV-negative

41/46(89.1)

4/4(100)

37/42(88.1)

5/46(10.9)

0/4(0)

5/42(11.9)

P value

Well-differentiated(grade I

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Tumor differentation

Poorly-differentiated(grade III) Immunophenotype

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and II)

NS

0/46(0)

0/4(0)

CD138

45/46(97.8)

4/4(100)

41/42(97.6)

NS

CD79a

33/46(73.9)

3/4(75)

31/42(73.8)

NS

Mum-1

46/46(100)

4/4(100)

42/42(100)

-

PC

43/46(93.5)

3/4(75)

40/42(95.2)

NS

CD56

13/46(28.2)

2/4(50)

11/42(26.2)

NS

CyclinD1

8/16(50)

1/4(25)

7/12(58.3)

NS

11/28

0/4

11/24

NS

25(5-40)

24.6(1-80)

NS

10/37(27)

0/4(0)

10/33(30.3)

NS

5/37(13.5)

1/4(25)

4/33(12.1)

NS

4/37(10.8)

0/4(0)

4/33(12.1)

NS

1/37(2.7)

0/4(0)

1/33(3.1)

NS

Median Ki-67

-

Cytogenetics

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Del13q14

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κ/λ

Del17p13 T(11;14)

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MYC

SC

CD20

§

0/42(0)

NS

-

*:Data are given as number positive/number tested (percentage) unless otherwise indicated. :Monotypic for κ or λ light chain expression.

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§

ACCEPTED MANUSCRIPT TABLE 4. Summary of literature reporting Epstein-Barr virus-positive plasmacytomas in immunocompetent SPs N

Gend

Ag

Immun

Tumor site

o.

er

e

e Status

Aguilera(

1-

NS

N

NS*

NS

11)

3

Tomita(1

4

compet

Ileum

7 8

F

49

M M

78 34

M

40

)

compet

9

Stomach

M

90

10

M

49

Submandib ular gland

compet

Ileocecal,ly

NS

NS

Plasmablastic

NS

NS

Plasmablastic

Resection,

ANED,90mon

R-CHOP

ths

compet

Resection,

ANED,75mon

RT

ths

NS*

Resrction

NS

Resection

ANED,14.7m

Well-different

mph nodes maxillary

Plasmablastic

sinus

penis

compet

Esophagus

ent

13

M M

AC

14

M

15 16

26

Well-different

73 61

M M

63 27 67

M

38

F

50

onths

Nasal

Well-different

Hyper-CV

ANED,59.9m

cavity

iated

AD, RT

onths

compet

Mediastinu

Well-different

N/A

ANED,42.6m

ent

m

iated

compet

Nasal

Well-different

ent

septum

iated

compet

Nasal

Well-different

ent

cavity

iated

compet

Nasal

Well-different

Resection,

ANED,70mon

ent

cavity

iated

RT

ths

compet

skull

Well-different

Resection,

DOD,55mont

iated

ADT

hs

Well-different

Resection

AWD,83mont

compet

Clavicle

ent 18

iated

ent

ent 17

Well-different

compet

PT

12

F

CE

11

ED

)

report

NS

iated

Loghavi(4

This

NS

iated

ent

(16)

Du(17)

Well-different iated

compet

ent

Scarberry

NS

T

46

ent Chang(15

NS

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Saito(14)

NS

RI P

M

ent 6

Outcome

features

ent

Yan(13)

Therapy

S

2) 5

Morphologic

SC

Author

compet ent

onths RT

onths RT

ANED,18mon ths

iated humerus

ANED,44.8m

hs

Well-different

Resection,

AWD,21mont

iated

RT

hs

Abbreviations: ANED: alive with no evidence of disease; AWD: alive with relapsing disease; F: female; M: male; MM: multiple myeloma; N/A: not available; No.: number; NS: not specified; RT: radiation therapy; R-CHOP: rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone; ADT:Doxorubicin, dexamethasone, Thalidomide *: Although not specifically mentioned, the authors do not describe any signs or symptoms of immunodeficiency in these patients.

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Figure 1

ACCEPTED MANUSCRIPT Highlights No significant difference in clinicopathologic, immunophenotypic and cytogenetic characteristics between EBV-positive and EBV-negative patients.

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No significant difference in overall survival time between EBV-positive and

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EBV-negative patients.

EBV-positive patients were significantly associated with disease progression

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SC

compared to EBV-negative patients.