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Bullous Pemphigoid Associated With Mantle Cell Lymphoma FREE

Pilar Iranzo, MD; Ingrid López, MD; Maria Teresa Robles, MD; José Manuel Mascaró Jr, MD; Elías Campo, MD; Carmen Herrero, MD
[+] Author Affiliations

Author Affiliations: Departments of Dermatology (Drs Iranzo, López, Robles, Mascaró, and Herrero) and Pathology (Dr Campo), Hospital Clinic, Universitat de Barcelona, and Department of Dermatology, Hospital Comarcal ĹAlt Penedés (Dr Robles), Barcelona, Spain.


Arch Dermatol. 2004;140(12):1496-1499. doi:10.1001/archderm.140.12.1496.
Text Size: A A A
Published online

ABSTRACT

Background  Bullous pemphigoid has developed in association with different types of malignant diseases, including a few cases of B-cell lymphoproliferative disorders. However, the paraneoplastic significance of this association is still controversial.

Observations  We describe a 39-year-old patient who presented with a bullous eruption and generalized lymphadenopathy. The results of histologic, immunofluorescence, and antigenic studies confirmed the diagnosis of bullous pemphigoid. The histopathologic and immunophenotypic features of a lymph node biopsy specimen were consistent with mantle cell lymphoma. There was total resolution of the mucocutaneous lesions when mantle cell lymphoma went into remission.

Conclusion  The age of the patient and the concomitant appearance and simultaneous remission of both diseases strongly suggest that bullous pemphigoid was a paraneoplastic phenomenon in the present case.

Figures in this Article

Bullous pemphigoid (BP), which is an acquired autoimmune subepidermal blistering disorder of the elderly, is characterized by the deposition of IgG and/or C3 along the basement membrane zone (BMZ) on direct immunofluorescence (DIF). Most patients have circulating IgG autoantibodies that can be demonstrated by indirect immunofluorescence (IIF). These antibodies bind to the epidermal side of the BMZ on salt-split skin. Bullous pemphigoid has been associated with different types of malignant diseases, but the paraneoplastic significance of this association is still unclear.14

Mantle cell lymphoma (MCL), which is a rare form of non-Hodgkin’s B-cell lymphoma, is derived from a subset of naive pregerminal center cells that are localized in primary follicles or in the mantle zones of secondary follicles. Morphological, immunophenotypic, and molecular features of this type of lymphoma have been well characterized in the last few years, allowing its accurate diagnosis.5,6 Mantle cell lymphoma has a distinctive clinical presentation. It usually affects elderly patients with generalized lymphadenopathy and bone marrow infiltration. Splenomegaly, Waldeyer ring, and gastrointestinal tract involvement are relatively common. Occasionally, patients present with a leukemic phase, which may be misinterpreted as small lymphocytic lymphoma or chronic lymphocytic leukemia. The course of MCL is usually aggressive, with a median survival time of 3 to 5 years. Prognostic factors are not well defined. Increased levels of lactate dehydrogenase and β2-microglobulin, poor performance status, peripheral blood involvement, blastoid variants, and proliferative activity of the tumor have been associated with a poor prognosis.6

The occurrence of autoantibody-mediated skin disease has been rarely reported in B-cell neoplasia, mainly in association with paraneoplastic pemphigus.7 However, immunologic disorders associated with MCL are unusual. We describe a patient who presented with BP associated with MCL. Both diseases had a parallel clinical course, suggesting a paraneoplastic phenomenon.

REPORT OF A CASE

A 39-year-old white man was admitted in February 1999 with a 3-month history of severe odynophagia resulting in 5-kg weight loss and a 6-week history of an extensive eruption of tense blisters and painful oral lesions. His medical history was not relevant, and he was not using any medications. Physical examination revealed a widespread eruption of tense serohemorrhagic blisters over erythematous plaques, predominantly on the extremities and scattered on the trunk (Figure 1). The Nikolsky sign was negative. The patient also had multiple erosions on the soft palate and floor of the mouth, generalized lymphadenopathy, and mild splenomegaly.

Place holder to copy figure label and caption
Figure 1.

Serohemorrhagic blisters on limbs.

Graphic Jump Location

A cutaneous biopsy specimen showed a subepidermal blister with abundant eosinophils in the inflammatory infiltrate. Direct immunofluorescence of a perilesional skin biopsy specimen revealed linear deposition of IgG and C3 along the BMZ (Figure 2), and IIF demonstrated the presence of IgG autoantibodies directed against the BMZ of rabbit lip in a serum sample and in blister fluid. The IgG autoantibodies bound to the epidermal side of 1M sodium chloride split skin, with a titer of 1:640.

Place holder to copy figure label and caption
Figure 2.

C3 deposition along the basement membrane zone on direct immunofluorescence of the perilesional skin.

Graphic Jump Location

On immunoblot analysis, the IgG antibodies from blister fluid reacted with the recombinant NC16A domain of BP180 and showed a faint IgG reactivity against LAD-1 (soluble ectodomain of BP180 obtained from keratinocyte-conditioned medium), and a serum sample showed strong IgG reactivity with LAD-1. A weak reactivity of IgA antibodies from both the blister fluid and the serum sample was also noted with LAD-1. A faint IgG reactivity with a 180-kDa protein was also detected when epidermal and keratinocytes extracts were used as substrate, while no reactivity was observed with BP230. The serum sample and blister fluid were both positive for NC16A reactivity on enzyme-linked immunosorbent assay.

A lymph node biopsy specimen showed a widespread effacement of the nodal architecture, which was replaced by a proliferation of small lymphocytes with scant cytoplasm and irregular nuclei, with persistence of some residual naked germinal centers (Figure 3). Immunophenotypic examination showed the expression of B-cell–associated antigens CD20 and CD79a, with coexpression of CD5 and CD43. The specimen was negative for CD10 and CD23. The neoplastic cells were positive for bcl-2 and IgD and negative for p53. The results of cyclin D1 immunostaining were unsatisfactory, but polymerase chain reaction demonstrated the presence of a bcl-1/JH rearrangement at the MTC locus.8 The proliferation rate tested with Ki-67 was low (<25%). The results of IIF were negative when the patient’s lymph node was used as a substrate.

Place holder to copy figure label and caption
Figure 3.

Lymph node biopsy specimen showing small lymphocytes with scant cytoplasm and irregular nuclei.

Graphic Jump Location

Laboratory investigations disclosed elevated levels of lactate dehydrogenase (508 U/L [reference range, 250-450 U/L]) and β2-microglobulin (2.9 μg/mL [246 nmol/L]) (reference value, <2.5 μg/mL [<212 nmol/L]). The results of a complete blood cell count and biochemistry profile were within normal limits.

A bone marrow biopsy specimen demonstrated infiltration by MCL. Peripheral blood examination demonstrated 62% malignant lymphocytes, with a CD5+,CD20+, CD23 immunophenotype and λ light chain restriction. Monoclonality was detected by polymerase chain reaction of the complementary determining region III of the heavy chain IgG locus.

A total body computed tomographic scan revealed the involvement of axillary, inguinal, iliac, peripancreatic, and gastrohepatic ligament lymph nodes, with a minimally enlarged spleen. The findings of fibrogastroscopic and fibrocolonoscopic examination were normal.

The patient was started on a regimen of oral prednisone (100 mg/d), with clinical improvement of his cutaneous lesions. When the diagnosis of MCL (stage IVa) was established, he was transferred to the hematology ward. In August 1999, he underwent an allogeneic bone marrow transplantation after cytoreduction with 2 courses of fractionated cyclophosphamide, doxorubicin hydrochloride, vincristine sulfate, and dexamethasone, which were alternated with high-dose methotrexate and cytosine arabinoside. Cyclosporine was also administered to prevent graft-vs-host disease, and the dosage was gradually tapered over a 2-month period.

During cytoreduction, the BP lesions gradually disappeared; since then, and after 48 months of follow-up, the patient has not required further topical or systemic therapy. There have been no signs of recurrence of neoplastic or cutaneous disease.

COMMENT

Since Lever9 established the criteria for the diagnosis of BP in 1953, many cases associated with malignant disease have been reported. There has been controversy about whether patients with BP have an increased likelihood of developing an underlying neoplasia compared with age-matched controls.

Chorzelski et al1 found that 11% of 110 cases of BP were associated with cancer. They regarded this incidence as highly significant, as they compared with the expectancy of cancer in the Polish population in a corresponding age and sex group. The statistical significance of their findings was later questioned because they compared 2 different populations. This percentage of cancer incidence is similar to that found by other authors,24,10,11 but they believed that the association was to be expected because both diseases are more common in the elderly.

It has been suggested that concurrent malignant disease and mucosal involvement occur more commonly in patients with BP and negative findings on IIF.12 The incidence and clinical significance of mucosal lesions in BP are still uncertain, but the lesions are more common in seronegative patients and do not appear to indicate a worse prognosis or therapeutic response.2 A correlation between negative IIF findings and malignancy has been supported by some authors,2,12 whereas others13 did not find a relationship between the presence or absence of circulating anti-BMZ antibodies and the development of malignancy.

In our case, as in the 3 cases associated with malignancy reported by Muramatsu et al,14 autoantibodies against BP180 but not against BP 230 were detected. To the best of our knowledge, disease activity correlated with levels of autoantibodies to BP180 NC16A, in contrast to IIF titers,15 but there have been no reports concerning the relationship between autoantibodies against BP180 and internal malignancies.

Venning and Wojnarowska16 compared the incidence of neoplasia in 84 patients with BP with that in 168 controls. The rate of concurrent BP and malignancy suggested that there was a slight increase in malignancy in patients with BP. They also compared patients with BP with and without neoplasia and only found a preponderance of females in the noncancer group. There were no differences in the prevalence of mucosal involvement, presence of circulating antibodies, or HLA type.

The relationship between tumors and BP can be explained by the production of antibodies to tumor-specific antigens that might cross-react with the BMZ. Another hypothesis suggests that tumor cells might secrete a substance that could damage the basement membrane, with secondary production of anti-BMZ antibodies. Other theories include the possibility that the same external agent might generate the cancer and the BMZ damage or that there is a genetic predisposition to both diseases.

In B-cell neoplasia, the occurrence of autoantibody-mediated skin disease has been reported, although rarely and mainly in association with paraneoplastic pemphigus.7Aractingi et al17 retrospectively reviewed the DIF results in skin biopsy specimens from 102 patients with B-cell lymphoproliferative disorders and cutaneous lesions. They found 2 cases of typical paraneoplastic pemphigus and 9 cases (8.9%) with linear dermoepidermal immunoglobulin or C3 deposition. They analyzed the antigenic specifity of the antibodies in 7 of the 11 cases. One patient had cicatricial pemphigoid, while the others had epidermolysis bullosa acquisita.

There are only a few reports on the association of BP with chronic lymphocytic leukemia, despite the numerous types of dermatologic lesions that can accompany this type of leukemia.1821 Modiano et al22 described 1 patient with refractory anemia and an excess of blast cells in transformation and IgM monoclonal gammopathy who developed a subepidermal blistering eruption, with a dermal infiltrate of CD13+ and CD15+ cells, showing linear deposits of IgG, IgM, and C3 at the BMZ on DIF examination. Immunoblotting of the patient’s serum sample revealed IgG antibodies against 3 protein bands: a 210- to 215-kDa band comigrating with desmoplakin 2, a 180-kDa band comigrating with BP180, and a 190-kDa band. The presence of antidesmoplakin antibodies could be the result of a cellular autoimmune disturbance in a patient with other autoimmune or hematologic diseases. Such antibodies could also be a consequence of the epidermal damage induced by the dermal tumor infiltrate and basement membrane antibodies.22

Bauduer et al23 described the simultaneous occurrence of BP and transformation of a preexisting myelodysplastic syndrome. Misery et al20 described 1 patient with chronic lymphocytic leukemia and BP in whom both disorders were diagnosed simultaneously. They speculated that BP might be induced by the production of antibodies by leukemic B cells, but this hypothesis could not be demonstrated in their study.

Egan et al24 described 1 patient with BP surrounding an urostomy site (for bladder cancer resection 12 years earlier) associated with a B-cell lymphoma. Although localized BP around a stoma can occur, the coincidental onset of BP and lymphoma in their patient and the regression of tumor mass and clinical improvement of the BP with chemotherapy also suggest a paraneoplastic phenomenon.

There are striking similarities between common genetic aberrations in MCL and CLL, suggesting that there may be similarities in the pathogenesis of the 2 diseases.6,2527 Mantle cell lymphoma has a very poor prognosis, but allogeneic hematopoietic transplantation can achieve molecular remissions.28

In our case, the presence of BP allowed the detection of MCL in stage IVa, before the patient’s general condition had deteriorated, and treatment was undertaken as early as possible. Forty-eight months after the diagnosis, the patient was still free of disease. The age of our patient and the simultaneous appearance and remission of both diseases strongly suggest that BP was a paraneoplastic phenomenon in the present case.

ARTICLE INFORMATION

Correspondence: Pilar Iranzo, MD, Department of Dermatology, Hospital Clínic, Universitat de Barcelona, c/Villarroel 170, 08036 Barcelona, Spain (piranzo@clinic.ub.es).

Accepted for Publication: May 5, 2004.

Acknowledgment: We thank Cassian Sitaru, MD, and Detlef Zillikens, MD, of the University of Würzburg, Würzburg, Germany, for performing the enzyme-linked immunosorbent assay and the immunoblot studies.

Financial Disclosure: None.

REFERENCES

Chorzelski  TPJablonska  SMaciejowska  EBeutner  EHWronkowski  L Coexistence of malignancies with bullous pemphigoid Arch Dermatol 1978;114964
PubMed Link to Article
Hodge  LMarsden  RABlack  MMBhogal  BCorbett  MF Bullous pemphigoid: the frequency of mucosal involvement and concurrent malignancy Br J Dermatol 1981;10565- 69
PubMed Link to Article
Stone  SPSchroeter  AL Bullous pemphigoid and associated malignant neoplasms Arch Dermatol 1975;111991- 994
PubMed Link to Article
Ahmed  ARChu  TMProvost  TT Bullous pemphigoid clinical and serological evaluation for associated malignant neoplasms Arch Dermatol 1977;113969
PubMed Link to Article
Banks  PMChan  JClearly  ML  et al.  Mantle cell lymphoma: a proposal for unification of morphologic, immunologic, and molecular data Am J Surg Pathol 1992;16637- 640
PubMed Link to Article
Campo  ERaffeld  MJaffe  ES Mantle cell lymphoma Semin Hematol 1999;36115- 127
PubMed
Anhalt  GJKim  SCStanley  JR  et al.  Paraneoplastic pemphigus: an autoimmune mucocutaneous disease associated with neoplasia N Engl J Med 1990;3231729- 1735
PubMed Link to Article
Pinyol  MCampo  ENadal  A  et al.  Detection of the bcl-1 rearrangement in frozen and paraffin embedded tissues of mantle cell lymphoma by polymerase chain reaction Am J Clin Pathol 1996;105532- 537
PubMed
Lever  WF Pemphigus Medicine 1953;321- 123
PubMed Link to Article
Lim  CCMcDonald  RHRook  AJ Pemphigoid eruptions in the elderly Trans St Johns Hosp Dermatol Soc 1968;54148- 151
PubMed
Lindelöf  BIslam  NEklun  GArfors  L Pemphigoid and cancer Arch Dermatol 1990;12666- 68
PubMed Link to Article
Person  JRRogers  R  III Bullous and cicatricial pemphigoid: clinical, histopathologic, and immunopathologic correlations Mayo Clin Proc 1977;5254- 56
PubMed
Ahmed  ARAmerian  ML Correlation of serum anti–basement membrane zone antibody and malignancy in bullous pemphigoid Dermatologica 1985;17182- 85
PubMed Link to Article
Muramatsu  TIida  TTada  H  et al.  Bullous pemphigoid associated with internal malignancies: identification of 180-kDa antigen by Western immunoblotting Br J Dermatol 1996;135782- 784
PubMed Link to Article
Schmidt  EObe  KBröcker  E-BZillikens  D Serum levels of autoantibodies to BP180 correlate with disease activity in patients with bullous pemphigoid Arch Dermatol 2000;136174- 178
PubMed Link to Article
Venning  VAWojnarowska  F The association of bullous pemphigoid and malignant disease: a case control study Br J Dermatol 1990;123439- 445
PubMed Link to Article
Aractingi  SBachmeyer  CProst  CCaux  FFlageul  BFermand  J-P Subepidermal autoimmune bullous skin diseases associated with B-cell lymphoproliferative disorders Medicine 1999;78228- 235
PubMed Link to Article
Cuni  LJGrünwald  HRosner  F Bullous pemphigoid in chronic lymphocytic leukemia with the demonstration of antibasement membrane antibodies Am J Med 1974;57987- 992
PubMed Link to Article
Goodnough  LTMuir  WA Bullous pemphigoid as a manifestation of chronic lymphocytic leukemia Arch Intern Med 1980;1401526- 1527
PubMed Link to Article
Misery  LCambazard  FRimokh  R  et al.  Bullous pemphigoid associated with chronic B-cell lymphatic leukaemia: the anti–230-kDa autoantibody is not synthesised by leukaemic cells Br J Dermatol 1999;141155- 157
PubMed Link to Article
Ameen  MPembroke  ACBlack  MMRussel-Jones  R Eosinophilic spongiosis in association with bullous pemphigoid and chronic lymphocitic leukaemia Br J Dermatol 2000;143421- 424
PubMed Link to Article
Modiano  PReichert  SBarbaud  ABernard  PWeber  MSchmutz  JL Bullous pemphigoid in association with cutaneous lesions specific to a myelodysplastic syndrome Br J Dermatol 1997;136402- 405
PubMed Link to Article
Bauduer  FBarteau  ATruchet  SMassot-Bordenave  JDucout  L Bullous pemphigoid associated with the transformation of a preexisting myelodysplastic syndrome Leuk Lymphoma 1999;32399- 400
PubMed
Egan  CAFlorell  SRZone  JJ Localized bullous pemphigoid in a patient with B-cell lymphoma South Med J 1999;921220- 1222
PubMed Link to Article
Bentz  MPlesh  ABullinger  L  et al.  t(11;14)-Positive mantle cell lymphomas exhibit complex karyotypes and share similarities with B-cell chronic lymphocytic leukemia Genes Chromosomes Cancer 2000;27285- 294
PubMed Link to Article
Bea  SRibas  MHernandez  JM  et al.  Increased number of chromosomal imbalances and high-level DNA amplifications in mantle cell lymphoma are associated with blastoid variants Blood 1999;934365- 4374
PubMed
Bea  SLopez-Guillermo  ARibas  M  et al.  Genetic imbalances in progressed B-cell chronic lymphocytic leukemia and transformed large-cell lymphoma (Richter’s syndrome) Am J Pathol 2002;161957- 968
PubMed Link to Article
Khouri  IFLee  MSRomaguera  J  et al.  Allogeneic hematopoietic transplantation for mantle-cell lymphoma: molecular remissions and evidence of graft-versus-malignancy Ann Oncol 1999;101293- 1299
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

Serohemorrhagic blisters on limbs.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

C3 deposition along the basement membrane zone on direct immunofluorescence of the perilesional skin.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Lymph node biopsy specimen showing small lymphocytes with scant cytoplasm and irregular nuclei.

Graphic Jump Location

Tables

References

Chorzelski  TPJablonska  SMaciejowska  EBeutner  EHWronkowski  L Coexistence of malignancies with bullous pemphigoid Arch Dermatol 1978;114964
PubMed Link to Article
Hodge  LMarsden  RABlack  MMBhogal  BCorbett  MF Bullous pemphigoid: the frequency of mucosal involvement and concurrent malignancy Br J Dermatol 1981;10565- 69
PubMed Link to Article
Stone  SPSchroeter  AL Bullous pemphigoid and associated malignant neoplasms Arch Dermatol 1975;111991- 994
PubMed Link to Article
Ahmed  ARChu  TMProvost  TT Bullous pemphigoid clinical and serological evaluation for associated malignant neoplasms Arch Dermatol 1977;113969
PubMed Link to Article
Banks  PMChan  JClearly  ML  et al.  Mantle cell lymphoma: a proposal for unification of morphologic, immunologic, and molecular data Am J Surg Pathol 1992;16637- 640
PubMed Link to Article
Campo  ERaffeld  MJaffe  ES Mantle cell lymphoma Semin Hematol 1999;36115- 127
PubMed
Anhalt  GJKim  SCStanley  JR  et al.  Paraneoplastic pemphigus: an autoimmune mucocutaneous disease associated with neoplasia N Engl J Med 1990;3231729- 1735
PubMed Link to Article
Pinyol  MCampo  ENadal  A  et al.  Detection of the bcl-1 rearrangement in frozen and paraffin embedded tissues of mantle cell lymphoma by polymerase chain reaction Am J Clin Pathol 1996;105532- 537
PubMed
Lever  WF Pemphigus Medicine 1953;321- 123
PubMed Link to Article
Lim  CCMcDonald  RHRook  AJ Pemphigoid eruptions in the elderly Trans St Johns Hosp Dermatol Soc 1968;54148- 151
PubMed
Lindelöf  BIslam  NEklun  GArfors  L Pemphigoid and cancer Arch Dermatol 1990;12666- 68
PubMed Link to Article
Person  JRRogers  R  III Bullous and cicatricial pemphigoid: clinical, histopathologic, and immunopathologic correlations Mayo Clin Proc 1977;5254- 56
PubMed
Ahmed  ARAmerian  ML Correlation of serum anti–basement membrane zone antibody and malignancy in bullous pemphigoid Dermatologica 1985;17182- 85
PubMed Link to Article
Muramatsu  TIida  TTada  H  et al.  Bullous pemphigoid associated with internal malignancies: identification of 180-kDa antigen by Western immunoblotting Br J Dermatol 1996;135782- 784
PubMed Link to Article
Schmidt  EObe  KBröcker  E-BZillikens  D Serum levels of autoantibodies to BP180 correlate with disease activity in patients with bullous pemphigoid Arch Dermatol 2000;136174- 178
PubMed Link to Article
Venning  VAWojnarowska  F The association of bullous pemphigoid and malignant disease: a case control study Br J Dermatol 1990;123439- 445
PubMed Link to Article
Aractingi  SBachmeyer  CProst  CCaux  FFlageul  BFermand  J-P Subepidermal autoimmune bullous skin diseases associated with B-cell lymphoproliferative disorders Medicine 1999;78228- 235
PubMed Link to Article
Cuni  LJGrünwald  HRosner  F Bullous pemphigoid in chronic lymphocytic leukemia with the demonstration of antibasement membrane antibodies Am J Med 1974;57987- 992
PubMed Link to Article
Goodnough  LTMuir  WA Bullous pemphigoid as a manifestation of chronic lymphocytic leukemia Arch Intern Med 1980;1401526- 1527
PubMed Link to Article
Misery  LCambazard  FRimokh  R  et al.  Bullous pemphigoid associated with chronic B-cell lymphatic leukaemia: the anti–230-kDa autoantibody is not synthesised by leukaemic cells Br J Dermatol 1999;141155- 157
PubMed Link to Article
Ameen  MPembroke  ACBlack  MMRussel-Jones  R Eosinophilic spongiosis in association with bullous pemphigoid and chronic lymphocitic leukaemia Br J Dermatol 2000;143421- 424
PubMed Link to Article
Modiano  PReichert  SBarbaud  ABernard  PWeber  MSchmutz  JL Bullous pemphigoid in association with cutaneous lesions specific to a myelodysplastic syndrome Br J Dermatol 1997;136402- 405
PubMed Link to Article
Bauduer  FBarteau  ATruchet  SMassot-Bordenave  JDucout  L Bullous pemphigoid associated with the transformation of a preexisting myelodysplastic syndrome Leuk Lymphoma 1999;32399- 400
PubMed
Egan  CAFlorell  SRZone  JJ Localized bullous pemphigoid in a patient with B-cell lymphoma South Med J 1999;921220- 1222
PubMed Link to Article
Bentz  MPlesh  ABullinger  L  et al.  t(11;14)-Positive mantle cell lymphomas exhibit complex karyotypes and share similarities with B-cell chronic lymphocytic leukemia Genes Chromosomes Cancer 2000;27285- 294
PubMed Link to Article
Bea  SRibas  MHernandez  JM  et al.  Increased number of chromosomal imbalances and high-level DNA amplifications in mantle cell lymphoma are associated with blastoid variants Blood 1999;934365- 4374
PubMed
Bea  SLopez-Guillermo  ARibas  M  et al.  Genetic imbalances in progressed B-cell chronic lymphocytic leukemia and transformed large-cell lymphoma (Richter’s syndrome) Am J Pathol 2002;161957- 968
PubMed Link to Article
Khouri  IFLee  MSRomaguera  J  et al.  Allogeneic hematopoietic transplantation for mantle-cell lymphoma: molecular remissions and evidence of graft-versus-malignancy Ann Oncol 1999;101293- 1299
PubMed Link to Article

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