Marginal zone lymphoma
Marginal zone lymphoma | |
---|---|
Other names | Marginal zone B-cell lymphoma |
EMZL infiltrating kidney tissue. | |
Types | Extranodal marginal zone lymphoma, splenic marginal zone lymphoma, and nodal marginal zone lymphoma. |
Marginal zone lymphomas, also known as marginal zone B-cell lymphomas (MZLs), are a heterogeneous group of
In 2016, the World Health Organization classified MZLs into three different types. Extranodal marginal zone lymphomas (EMZLs) are MZLs that develop in extranodal tissues. Most EMZLs develop in MALT and are often termed extranodal MZL of mucosa-associated lymphoid tissue or, more simply, MALT lymphomas. Splenic marginal zone lymphomas (SMZLs) are MZLs that initially are confined to the spleen, bone marrow, and blood.[1] Nodal marginal zone lymphomas (NMZs) are MZLs initially confined to lymph nodes, bone marrow, and blood.[1] While all of these MZL involve malignant B-cells, they differ not only in the tissues they involve but also in their pathophysiology, clinical presentations, prognoses, and treatments.[1][4]
MZLs represent 5–17% of all Non-Hodgkin lymphomas with the extranodal, splenic, and nodal forms accounting for 50–70%, ~20%, and ~10% of all MZLs.[5] The three MZL subtypes occur more often in older people (age 65–68 years) and are indolent diseases that may, in people without symptoms, be initially treated by a watchful waiting strategy. However, NMZL carries a somewhat worse long term outcome than the other subtypes[1] and any of the MZL subtypes may progress in a low percentage of cases to a more aggressive lymphoma, particularly diffuse large B-cell lymphoma.[6] One of the most distinctive feature of MZL is that many cases are associated with the persistent simulation of the immune system by the chronic inflammation that accompanies infections[7] or autoimmune diseases.[8] MZL cases associated with certain infectious pathogens can be cured by treatment directed at the pathogens causing or associated with these infections.[7]
Extranodal marginal zone lymphoma
Extranodal marginal zone lymphomas (EMZLs) are a form of MZL
Pathophysiology
Numerous factors appear to be involved in the development of EMZL. In a small number of cases where there is a family history of a
- chimeric protein promotes the continuous activation of a transcription factor, NF-κB. NF-κB controls the expression of various genes which increase the survival, cytokine production, and other potentially malignant behaviors of cells. 2) A t(14;18)(q32;q21) translocation occurs in 7% of ocular adnexa, 6% of lung, and rarely if at all in other cases of EMZL. It causes the overexpression of Malt1. This protein indirectly inhibits programmed cell death to prolong cell survival and also promotes activation of NF-κB. 3) A t(1;14)(p22;q32) ("p" stands for a chromosome's short arm) translocation occurs in ~9% of lung, ~4% of stomach, and rarely if at all in other cases of EMZL. This translocation causes the overexpression of the BCL10 gene. Bcl10 protein contributes to the activation of NF-κB. 4) A t(3;14)(p13;q32) translocation occurs in rare cases of EMZL and is thought to cause overexpression of the FOXP1 gene. FoxP1 protein stimulates production of transcription factors such as PRDM1, IRF4, and XBP1 which promote the maturation of B-cells to plasma cells. 5) Three translocations, t(1;14)(p21;q32), t(5;14)(q34;q32), t(9;14)(p24;q32), and t(X;14)(p11.4;q32), occur in rare cases of EMZL but their effects on promoting malignancy are unknown.[13]
- Gene inactivations and mutations: 1) NOTCH2 (8% of all cases) genes occur in EMZL. The products of these genes are cell surface receptor proteins which when bound to their activating ligands move to the cell nucleus and contribute to the activation of genes that control the development, proliferation, survival, and migration of B cells.[14]
Many EMZL subtypes are associated with infectious agents or autoimmune diseases that may contribute to their malignant development. The following Table reports on these EMZL subtypes; the tissues they involve; the infectious agents/autoimmune diseases that may underlie the development of the EMZL subtypes; the strength of evidence linking these infectious agents/autoimmune diseases to their malignancy; the incidence (i.e. percentage) of cases with the EMZL subtype associated with the infectious agent/autoimmune disease; and some of the chimeric genes expressed by the neoplastic B-cells of the EMZL subtype.[citation needed]
Subtype | Tissue(s) involved | Infectious agent or autoimmune diseasen[7] | Strength of evidence | Incidence[7][15] | Chimeric genes expressed (percentage of cases)[15] | |
---|---|---|---|---|---|---|
Primary gastric EMZL | stomach | Helicobacter pylori | confirmed[7][16] | ~80% | BIRC3-MALT1 (23%), IGH-FOXP1 (3%), IGH-BCL-10 (2%), and IGH-MALT1 (1%) | |
Primary gastric EMZL | stomach | Helicobacter heilmannii sensu lato | likely[7][15] | <1% | similar to the antibiotics used for Helicobacter pylori[17] | |
Primary salivary gland EMZL | salivary and lacrimal glands | Sjögren syndrome | confirmed[7][18] | ~4.3% | IGH-MALT1 (6%), BIRC3-MALT1 (2%), and IGH-BCL-10 (1%) | |
Primary thyroid EMZL | thyroid gland |
Hashimoto's thyroiditis | confirmed[7][18] | ~0.5% | ICH-FOXP1 (50%) and BIRC3-MALLT1 (9%) | |
Primary ocular adnexa EMZL | ocular adenexa (i.e. orbit, conjunctiva, and eyelids) | Chlamydia psittaci | suggestive[7][19] | 10–50% | IGH-FOXP1 (20%), IGH-MALT1 16%), and BIRC3-MALT1 (7%) | |
Primary cutaneous EMZL | skin | Borrelia burgdorferi | suggestive[19] | variable | IGH-FOXP1 (10%), IGH-MALT1 (7%), and BIRC3-MALT1 (4%) | |
Primary small intestinal EMZL | small intestine | Campylobacter jejuni | low[19][3] | variable | BIRC3-MALT1 (19%) and IGH-BCL10 (7%) | |
Primary pulmonary EMZL | lung | Achromobacter xylosoxidans | low[20][21] | <50% | BIRC3-MALT1 (45%), IGH-BCL10 (8%), and IGH-MALT1 (7%) |
Histopathology
The
Subtypes, diagnosis, treatment, and prognosis
There are various EMZL subtypes based on the organs they involve. Almost all of these subtypes occur in the mucosa-associated lymphoid tissue of the affected organ and are often termed MALT lymphomas of the affected organ (e.g. gastric MALT lymphoma). However, these lymphomas are also termed primary EMZL of the affected organ (e.g. primary gastric EMZL). While both terms are used here for these subtypes, the primary (organ involved) EMZL is preferred to indicate that the EMZL subtype initially developed in and may remain limited to the indicated tissue. However, approximately 30% of cases disseminate to other sites, predominantly lymph nodes and in rare cases the bone marrow. The malignant B-cells in these subtypes may also circulate in the blood but this is very uncommon. Regardless of the subtype of EMZL or its dissemination to other tissues, the prognosis for these lymphomas is good with 5 year overall survivals generally ranging between 86% and 95%.[15][6]
Primary gastric
Primary gastric EMZL, also termed primary gastric MALT lymphoma or, more often, just gastric MALT lymphoma, is usually an indolent disease that in ~10% of cases also involves other GI tract and/or non-GI tract sites. Patients commonly present at an early stage of the disease
Primary small intestinal
Primary small intestinal MZL, also termed primary small intestinal MALT lymphoma, commonly presents with
In primary small intestinal EMZL cases,
The Treatment of primary small intestinal EMZL has focused on nutritional support and control of symptoms including surgery and/or radiotherapy to treat bowel obstructions and highly localized disease. However, studies indicate that individuals with the disease, particularly those with the immunoproliferative small intestine disease form, have overall response rates of ~90% following treatment with broad-spectrum antibiotics such as tetracycline, metronidazole, or tetracycline + ampicillin.[3] These responses are durable in most cases. Accordingly, antibiotic therapy is recommended to treat early stage disease. Patients refractory to antibiotic therapy have been treated with chemotherapy (i.e. CHOP or a CHOP-like regimes) followed by long-term maintenance with tetracycline. This treatment regimen has achieved 5 year overall survival rates of 70%. Since surgery and radiotherapy are not curative for the disease, high dose chemotherapy regimens and autologous stem cell transplantation have been recommended for refractory and/or relapsed disease.[2]
Colorectal EMZLs
EMZLs involving the colon or rectum are extremely rare. In a 2019 review of 73 cases, persons diagnosed with one of these EMZL subtypes had a median age of 62 years (range 26–72), were predominately female (66%), and had their primary tumors located in the rectum (74% of cases), right colon (13.6%), transverse colon (4.1%), or sigmoid colon (8.2%). Thirty percent of these individuals had multiple tumors, ~40% of which were in sites in the gastrointestinal tract outside of the colon and rectum. These individuals were initially treated and achieved complete remissions with local surgical resection in 18 of 19 cases, more extensive surgical resection in 18 of 19 cases, chemotherapy in 12 of 13 cases, radiation therapy (in 4 of 5 cases, or antibiotic therapy to achieve Helicobacter pylori eradication in 12 of 15 cases. Two individuals received no treatment with one of these having a spontaneous remission. The 8 cases not achieving a complete remission required second-line treatment; 3 cases were remission failures.[29] The following sections further describe these two EMZL subtypes.
Primary colonic
Primary colonic EMZL, also termed primary colonic MALT lymphoma, usually presents at an early stage of disease with evidence of lower GI tract bleeding (e.g. tarry bowel movements and/or iron deficiency anemia), less commonly with lower abdominal pain, and rarely with bowel perforation or intussusception. Endoscopic examination most often reveals a single polyp or rarely multiple polyps, a mucosal ulcer, or a mucosal nodule. Diagnosis is passed on biopsy of the lesions showing a histology typical of EMZL, e.g. diffuse infiltrates composed of small to medium-sized lymphocytes that may show morphological features of monocytes and/or plasma cells. The lymphocytes in these lesions express B cell markers (e.g. CD19 and CD79a) typical of EMZL lesions. The best treatment regimen for this lymphoma is debated. Surgical resection, endoscopic resection, radiation, and chemotherapy have been employed. Surgery followed by chemotherapy (mitoxantrone + chlorambucil + prednisone or cyclophosphamide + vincristine + prednisone combined with either chlorambucil or rituximab) have been regarded as first-line treatment for the disease. More recently, rituximab alone as a single agent has also been found successful in treating primary colonic MALT lymphoma. Finally, rare cases of primary colonic EMZL have been completely resolved using Helicobacter pylori antibiotic therapy.[10]
Primary rectal
Primary rectal EMZL, more commonly termed MALT lymphoma of the rectum, usually presents at an early stage of disease with anal bleeding and/or
Primary esophagus
Primary EMZL of the esophagus, also termed MALT lymphoma of the
Primary ocular adnexa
Primary ocular
Patients present with conjunctival (25% of cases) or intra-orbital (75% of cases) lesions which typically involve one eye but in 10-15% of cases, particularly in conjunctival cases, involve both eyes. Conjunctiva lesions usually present as a salmon red patch that covers the outer layer of the eyeball; intra-orbital lesions commonly present as
Treatment of the disease requires further study. In patients with localized disease: 1) radiotherapy has achieved complete responses in 52-93% of cases and 5 year systemic-free (but not local-free) relapse rates of >90%; 2) chemotherapy with a CHOP regimen in 15 patients has achieved remissions without relapse in 9, local relapse in 5, and systemic relapse in 2 patients after 55 months of follow-up; 3) chemotherapy with chlorambucil in 33 patients has achieved complete responses in 26 patients after 24 months of follow-up; 4) immunotherapy with rituximab has achieved variable results over the short-term and requires further study over longer follow-up periods[37] with somewhat better results occurring in patients with conjunctival disease;[35] and 5) antibiotic therapy with doxycycline has achieved 2 year and 5 year failure-free survival rates of 67% and 55%, respectively, and a 5-year progression-free rate of 61%.[37] The generally recognized treatment of choice for patients with systemic involvement uses various chemotherapy regimens often combined with rituximab. Complete responses have been observed in most patients treated with chlorambucil, CHOP regimens, or rituximab but recurrence rates have been high (e.g. ~33%).[35]
Primary skin
Primary cutaneous EMZL or primary cutaneous MALT lymphoma (also termed skin-associated lymphoid tissue lymphoma) typically presents as single or multiple small
Primary lung
Primary pulmonary EMZL (or primary pulmonary MALT lymphoma) is a rare disorder but nonetheless represents up to 80% of all lymphomas originating in the lung. The cause for developing this lymphoma is unclear. Some 16% of individuals with the disease present with features of an autoimmune disorder with one study reporting that 57 of 124 patients with the disorder evidenced
Treatment of primary pulmonary EMZL varies. Antibiotic therapy has not been studied and cannot be recommended. Recommended treatments which have afforded overall 5 year survival rates of 89-100%[43] include surgery, radiotherapy, chemotherapy, immunotherapy, and watchful waiting.[42] Surgical resection or radiotherapy may be considered for localized disease. In more extensive disease, rituximab immunotherapy has achieved a 70% response rate but with a high rate of recurrence (~36%). Treatment with fludarabine, CHOP, chlorambucil, or chlorambucil + rituximab have been used to treat extensive disease with each treatment giving approximately similar overall median survival times of >10 years.[42]
Primary salivary gland
Primary salivary gland EMZL (also termed MALT lymphoma of the
Treatment of primary salivary/lacrimal gland EMZL has not been standardized. A minority of patients have been treated by watchful waiting but most patients have been subjected to surgery, radiotherapy, chemotherapy (i.e. chlorambucil), immunotherapy (i.e. rituximab, or a combination (e.g. chlorambucil + rituximab or fludarabine + rituximab or bendamustine + rituximab) immunotherapy plus chemotherapy regimen. In general, overall survival rates after 5, 10, and 15 years of treatment have been 95%, 85%, and 78% respectively. While the response to these therapeutic regimens has been very good, ~33% of treated patients have experience a recurrence of their lymphoma in the salivary/lacrimal glands, lymph nodes, or other sites.[20]
Lymphoepithelial sialadenitis
Primary thyroid
Primary thyroid EMZL, also termed MALT lymphoma of the
Treatment of primary thyroid EMZL is generally conservative since up to 90% of patients are diagnosed with early stage disease.[18] Although the optimal treatment for this disease is uncertain, the majority of patients with localized disease are treated with surgery, radiotherapy, or a combination of both modalities and attain overall response rates of up to 100%[20] and an estimated 5 year disease-free survival of 95%.[18] Surgery plus radiotherapy does not appear to give better results that radiotherapy alone.[45] Patients with extensive disease or disease that has progressed to a higher grade lymphoma (principally diffuse B-cell lymphoma) have been treated with chemotherapy (usually CHOP[45][46]) and/or immunotherapy (i.e. rituximab[45]). However, the 5 year survival rates in chemotherapy-treated patients with disseminated primary thyroid EMZL[47] or disease that has progressed to a more malignant lymphoma[18] are only 35% and 44%, respectively.
EMZL and other autoimmune diseases
Patients with an
Primary central nervous system
Primary EMZL of the
Treatment of localized disease consisted of surgery, radiotherapy, or a combination of both modalities whereas treatment of extensive central nervous system disease consisted of chemotherapy, including intrathecal chemotherapy, with or without surgery and/or radiotherapy. Regardless of treatment regimen, primary central nervous system EZML has a good prognosis with complete response (CR) occurring in 77% of patients and 22% of patients alive with evidence of disease after 1–86 months of follow-up times. The values of systemic and intrathecal chemotherapy in treating the disease are unclear and require further study.[50]
Primary breast
Primary EMZL of the breast (also termed primary MALT lymphoma of the breast) is an exceedingly rare disease. It usually presents as a palpable breast mass in an otherwise symptom-free patient.[52] Histopathological findings are typical for EMZL: lesions consist of small- to medium-sized B cells, centrocyte-like B-cells, small lymphoid cells with some features of plasma cells or monocytes, and mature plasma cells with the lymphoid cells in these lesions expressing CD20 and CD79a but usually not CD10, CD43 or BCL6 marker proteins.[53] Moderate doses of local radiation therapy are recommended to treated localized EMZL of the breast. This treatment has achieved overall survival rates of >90%. Given these results and the high sensitivity of EMZL to radiation therapy, mastectomy is not recommended and wide excision is not usually necessary to treat localized disease. For patients with disseminated disease, treatment options include watchful waiting and chemotherapy (typically employing a CHOP or CHOP-like regimen) with or without radiation therapy and/or excision. These approaches have attained complete disease remissions in 9 of 9 patients followed for 6–74 months and one death due to progressive disease in a patient followed for 107 months. Other drugs used to treat the disease include rituximab, tamoxifen, and oxaliplatin.[52]
Primary urinary tract
Primary
Primary bladder
Presenting symptoms of primary bladder lymphoma include weight loss, fatigue,
Kidney
Kidney EMZL (i.e. kidney MALT lymphoma, renal EMZL, or renal MALT lymphoma) occurs primarily in individuals >50 years old but has been reported in individuals as young as 9 years. In slightly more than half of the reported cases, this lymphoma was localized to the kidney or detected in the kidney plus lymph nodes around the kidney, elsewhere in the
Primary gallbladder
Primary
Primary hepatic
Primary hepatic EMZL (i.e. primary hepatic extranodal marginal zone B-cell lymphoma, primary hepatic mucosa-associated lymphoid tissue lymphoma, primary hepatic mucosa-associated lymphoma) is an extremely rare malignancy representing <3% of all primary lymphomas of the liver.
EMZL associated with hepatitis C
EMZL occurs more frequently (~2.5-fold increased risk) in individuals who have
Splenic marginal zone lymphoma
Splenic marginal zone lymphoma (SMZL) is a low grade lymphoma in which malignant B-cells accumulate in the spleen, bone marrow, and, less commonly, the circulation. While generally an indolent disease, about 5-10% of cases transform into a far more aggressive malignancy, diffuse large B-cell lymphoma.[64] In a variable percentage of cases, SMZL has been observed to occur with an increased incidence in individuals who are chronically infected with Hepatitis C virus[63] or have any one of various chronic autoimmune diseases or abnormalities.[65]
Signs and symptoms
At presentation, patients (median age 65 years; range 30–90 years) generally exhibit enlargement of their spleens (75% of cases).
Pathophysiology
The malignant cells involved in SMZL are tentatively identified as antigen-experienced B-cells. The disease appears to be initiated in at least some cases by chronic antigen stimulation of the precursor B-cells that thereby become antigen-experienced. Evidence for this derivation comes from studies showing that the antigen-experienced B-cells inn SMZL express structurally restricted
- Chromosome abnormalities such as: 1) deletions in the long (i.e. "q") arm of chromosome 7 (annotated as del7q) in 30-40% of cases (this deletion is rare in other lymphomas and therefore used as a marker for SMZL);tumor suppressor that acts to regulate cellular survival; and 3) gains in the q arm of chromosome 3 in 10-20% of cases.[66]
Overall, mutations in the NOTCH, NF-κB, and KLF2 signaling pathways appear particularly important in the pathogenesis of SMZL.[65]
Diagnosis
The clearest evidence for the diagnosis of SMZL is obtained by examination of patients' spleens obtained by
Treatment
Given its rarity, there have been no systematic and controlled studies on the treatment of SMZL. Current recommendations for this include the following. Watchful waiting, which is the withholding of specific treatments while performing follow-up examinations every 3 to 6 months to detect disease progression. This course is recommended for the ~33% of SMZL patients who present with asymptomatic, non-progressive, or slowly progressive disease. These patients may not require therapeutic interventions for long periods. Historically, the initial therapy for patients with rapidly progressing disease was splenectomy. Some 90% of these patients show reductions in their symptoms and improvements in their low red blood cell, platelet, and white blood cell counts; they had median progression-free, 5 year overall, and 10 year overall survival rates of 8.2 years, 84%, and 67%, respectively. However, these patients show no alteration in the neoplastic B-cells levels in their blood, were subject to serious complications from their splenectomy (e.g. thrombosis, infections), and did not show alter overall survival rates better than those obtained with other treatment strategies. Accordingly, splenectomy for SMZL has been limited to cases of significantly symptomatic enlarged spleens in patients with mild-to-moderate bone marrow involvement and no bulky lymph node enlargements.[67]
Current treatment recommendations for patients with symptomatic or rapidly progressive SMZL rely on drugs.
Experts recommend that SMZL patients who also have hepatitis C virus infection should be treated with drugs that act to eliminate the virus as their first line approach. Before the development of directly acting anti-viral agents, several studies reported that IFN-α treatment of these patients produced improvements not only in the viral infection but also remissions (~65% of cases) in their lymphomas.[67] Several newer, directly acting anti-viral agents, e.g. grazoprevir, daclatasvir, sofosbuvir, and dasabuvir, are more effective in treating hepatitis C viral infection[62] and in s small number of patients have been or are expected to be more effective in producing lymphoma remissions in patients with SMZL plus hepatitis C virus infection.[62][67]
Prognosis
SMZL generally follows an indolent course with 10 year survival rates of 42-95%.[66] About one-third of these deaths are unrelated to SMZL and ~5-10 of these deaths are due to the transformation of their SMZL disease to diffuse large C-cell lymphoma.[67]
Nodal marginal zone lymphoma
Nodal marginal zone lymphoma (NMZL), previously termed monocytoid B-cell lymphoma, nodal monocytoid B-cell lymphoma, and nodal marginal zone lymphoma with or without monocytoid B-cells, is an infiltration of tissues with malignant lymphoid cells that have the
Signs and symptoms
Almost all patients with NMZL present (median age 50–64 years;]
Pathophysiology
Some 6-19% of NMZL cases have been reported to be associated with autoimmune diseases such as rheumatoid arthritis, Sjögren syndrome, autoimmune hemolytic anemia, and chronic thyroiditis. However, there is little evidence that these diseases contribute to the development of NMZL.[75] Furthermore, the association of NMZL with hepatitis C virus infections found in earlier studies has not been confirmed in more recent studies.[74] It therefore appears that the postulated role of chronic immune stimulation in promoting extranodal and splenic marginal zone lymphomas has not been clearly demonstrated in and may not apply to NMZL: the underlying initiating cause for developing this disease is currently unclear. Nonetheless, instigating B-cells in NMZL acquire genomic abnormalities that are thought to contribute to their malignant transformation.[citation needed] These genomic abnormalities include the following.
- Chromosomal abnormalities such as: 1) trisomy of chromosome 3 (24% of cases) which causes the overexpression of FOXP1, NFKBIZ, and BCL6 whose protein products promote cellular proliferation and survival;[72] 2) trisomy of chromosome 18 (~50% of cases) causing the overexpression of NFATC1[72] whose protein product may act to promote cell proliferation and survival;[76] 3) uncommonly, trisomy of chromosomes 7 and 12 and deletion of the long arm of chromosome 6 which have as yet unknown functional effects;[72] and 4) chromosomal translocation between the short (i.e. "p") arm of chromosome 2 at position 24 and the long (i.e. "q") arm of chromosome 14 at position 32, a translocation of as yet unknown functional consequence but not found in the other marginal zone lymphoma forms and therefore useful as a diagnostic marker for NMZL.[77]
- Mutations in genes such as: 1) CREBBP, and TBL1XR1) that have chromatin remodeling activity to thereby regulate the expression of a wide range of other genes.[68]
Diagnosis
The diagnosis of NMZL depends upon identifying neoplastic B-cells in lymph nodes and in some cases the bone marrow but not, at least in early stage disease, in extra-nodal organs. These neoplastic cells should express the marker proteins common to marginal zone lymphomas (refer to previous section) and, in most cases, one or more of the genomic abnormalities indicated in the Pathophysiology section.[72]
Treatment
Recommended treatments for NMZL depend on the diseases state. Asymptomatic NMZL may use watchful waiting with routine follow-up examinations every, e.g. 3–6 months, to check for disease progression. However, localized disease, even in asymptomatic patients, has been successively treated with surgery followed by local radiotherapy. Disease that moves past a localized stage to become disseminated, rapidly progressive disease, and symptomatic disease have been treated with a single chemotherapy drug (e.g. cladribine, fludarabine, chlorambucil, or bendamustine); a single immunotherapy drug (e.g. rituximab); a multiple drug chemotherapy regimen (e.g. CHOP), or a combination multiple chemotherapy drug plus immunotherapy drug regimen (i.e. CHOP + rituximab). It is not clear that any one or more of these regimens achieves is superior to the others.[74]
Prognosis
NMZL is considered an incurable but relatively indolent disease that takes a slowly progressive, relapsing course. Its prognosis appears to be slightly worse than that seen in extranodal and splenic marginal zone lymphomas[72] with ~15% of people progressing to a more aggressive lymphoma, diffuse large B cell lymphoma, at median time of ~4.5 years after the diagnosis of NMZL.[74] In different studies, people with the disease have 5 year survival rates of 62-90%.[74]
Children
In children NMZL has been classified by the
Recent research
Various new drugs such as
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