Nodal Marginal Zone Lymphoma (NMZL) is a rare type of non-Hodgkin’s B-cell lymphoma that affects the lymph nodes. It is a slow-growing tumor that is mostly seen in older adults, but may affect younger individuals as well.
What are the other Names for this Condition? (Also known as/Synonyms)
- Nodal MZL
- NMZL (Nodal Marginal Zone Lymphoma)
What is Nodal Marginal Zone Lymphoma? (Definition/Background Information)
- Marginal Zone Lymphoma (MZL) is a slow-growing B-cell non-Hodgkin’s lymphoma affecting adults. Marginal Zone Lymphomas are typically not very aggressive and have better prognosis compared to other B-cell lymphomas
- They constitute approximately 10% of all B-cell lymphomas. There are 3 types of MZLs that include:
- Nodal Marginal Zone Lymphoma
- Extranodal Marginal Zone Lymphoma
- Splenic Marginal Zone Lymphoma
- Nodal Marginal Zone Lymphoma (NMZL) is a rare type of non-Hodgkin’s B-cell lymphoma that affects the lymph nodes. It is a slow-growing tumor that is mostly seen in older adults, but may affect younger individuals as well
- The cause of the condition is generally unknown, though certain genetic may be involved. However, Nodal Marginal Zone Lymphoma is observed to be associated with various other conditions such as hepatitis C viral infection, Sjögren’s syndrome, and poor immunity
- In a majority of individuals, there may be no signs and symptoms of Nodal Marginal Zone Lymphoma. In others, the lymph nodes of the head and neck region may be affected. There may be other general symptoms such as fatigue, weight loss, and frequent infections
- The healthcare provider may suggest a ‘wait and watch’ approach to monitor progress of Nodal Marginal Zone Lymphoma, if it remains asymptomatic. Nevertheless, chemotherapy, radiation therapy, or targeted therapy may be employed in case of significant symptoms
- The prognosis depends on many factors including the type of lymphoma, progression of the condition, response to treatment, and overall health of the individual. In general, the prognosis of Nodal Marginal Zone Lymphoma is good with appropriate treatment
General information on lymphoma and lymphocytes:
- Lymphoma is a type of cancer stemming from uncontrollably dividing lymphocytes (type of white blood cells). There are two types of lymphomas:
- Hodgkin lymphoma
- Non-Hodgkin lymphoma
- Lymphocytes are the main white blood cells found in the lymph, which is the fluid of the lymphatic system; just as blood is the fluid of the circulatory system
- Lymphocytes are made in bone marrow, and can develop into either B-cells or T-cells. Nodal Marginal Zone Lymphoma arises from cancerous B-cells
- Lymph results from filtration of blood as it travels to and from tissues. Lymph is colorless because it lacks red blood cells; instead, it contains lymphocytes. It is central to the immune system
- There are 3 different kinds of lymphocytes:
- T-lymphocytes or T cells: They help combat infections and abnormalities within the cells (cell-mediated immunity). They fight viruses and cancerous cells
- B-lymphocytes or B cells: They produce antibodies that are bodily defense proteins, which target foreign invaders outside the cells (humoral immunity). They fight bacterial cells, cell fragments, and other immunogenic elements
- Natural killer cells or NK cells: They perform diverse functions related to both cell-mediated and humoral immunity. They also scout for cancer cells, a process called immune surveillance
Who gets Nodal Marginal Zone Lymphoma? (Age and Sex Distribution)
- Nodal Marginal Zone Lymphoma is an uncommon condition that forms about 2% of all non-Hodgkin’s B-cell lymphoma
- This lymphoma type generally affects elderly adults; average age at diagnosis is 60 years. Both men and women can be affected in an equal incidence
- Sometimes, NMZL can be seen in young adults and children too. In this age category, the male-female ratio is 4:1
- It can occur worldwide and all races and ethnic groups may be affected
What are the Risk Factors for Nodal Marginal Zone Lymphoma? (Predisposing Factors)
No specific risk factors have been identified for Nodal Marginal Zone Lymphoma. However, the condition is known to be associated with the following factors:
- Sjögren’s syndrome - an inflammatory disorder causing dry eyes and dry mouth
- Hepatitis C virus (HCV) infection
- Waldenstrom’s macroglobulinemia; another type of B-cell non-Hodgkin’s lymphoma
- Advanced age; older individuals commonly have a higher risk
- Individuals with weak immune system (due to various health conditions)
Besides the above, the following general factors may contribute towards lymphoma formation and development:
- Family history of immune disease
- The presence of any systemic disease
- Exposure to radiation and industrial chemicals
- Viruses (in some rare cases); Epstein-Barr virus infection
- X-ray, CT scan exposure
- Profession involving radiation exposure, which may include nuclear plant workers, pilots, astronauts, etc.
- Certain medications and drugs
International Prognostic Index: According to some scientists, the International Prognostic Index may not be very helpful in evaluating Nodal Marginal Zone Lymphoma. However, some scientists believe that it is helpful in some cases, to determine the prognosis.
The International Prognostic Index, for aggressive non-Hodgkin Lymphoma, lists a few factors that determine the overall risk:
- Age over 60 years
- Elevated level of serum lactate dehydrogenase - LDH (a type of enzyme)
- Performance status, i.e. the overall health condition of the individual, which could range from being fully active (low risk) to being completely disabled (very high risk)
- Individual, who have already suffered from lymphoma, or other types of blood cancers, may have a relapse or a recurrence
- Presence of an immunodeficiency syndrome, like AIDS, is a high risk factor
- Those infected with Epstein-Barr virus
It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases ones chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.
Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.
What are the Causes of Nodal Marginal Zone Lymphoma? (Etiology)
Lymphocytes are a type of white blood cells that are responsible for providing immunity in the human body. B-cells and T-cells are the two different types of lymphocytes. When under certain circumstances, the lymphocytes grow and multiply abnormally, it leads to a condition called as lymphoma, which is a most common type of cancer. There are 2 types of lymphoma:
- Hodgkin lymphoma
- Non-Hodgkin lymphoma
The causative factors of Nodal Marginal Zone Lymphoma are unknown. It may be caused by genetic mutations. Also, there may be certain genetic defects, such as translocation, which is a juxtaposition of regions of chromosomes resulting in:
- Change of regulatory elements of certain cancer-causing genes called as oncogenes, which can lead to increased production of their mRNA (overexpression), thus increasing their protein levels
- Exchange of protein coding regions of gene, giving rise to new proteins that can stimulate the inappropriate growth of cells
It is believed that the abnormal development of lymphocytes gives rise to cancerous cells leading to the formation of this condition. Nevertheless, how this occurs and the factors that cause it remain under investigation.
What are the Signs and Symptoms of Nodal Marginal Zone Lymphoma?
In many individuals, the condition may be asymptomatic. In others, the signs and symptoms of Nodal Marginal Zone Lymphoma may include:
- The lymph nodes of the head and neck region are generally affected
- Presence of enlarged lymph nodes in the neck, armpits, or groin, which may be painless
- Unintentional weight loss; changes in appetite
- Fatigue and weakness, headache
- High temperatures and excessive night sweats (may be recurrent)
- Anemia (low red blood cell count)
- Low lymphocyte count, established by a blood test
- Frequent infections
- Trouble breathing
- Low blood pressure
- Back pain
- Swelling of the legs
- Abdominal pain and swelling; constipation
- Frequent urination
When there is an involvement of other organs and body parts, there may be specific signs and symptoms such as:
- Associated autoimmune disorders, which can cause joint and muscle pain, heat intolerance, recurrent rashes, abdominal pain, and a general feeling of illness
- If the brain is involved, then neurological symptoms such as the following may be observed:
- Tinnitus (ringing in the ears)
- Hearing and visual impairment
- If the gastrointestinal (GI) tract is involved, then GI tract symptoms such as the following may be observed:
- GI bleeding
- Liver and spleen enlargement
- Joint inflammation and fluid accumulation (edema) can occur, if the joints are affected
- The involvement of bone marrow and peripheral blood is uncommon
How is Nodal Marginal Zone Lymphoma Diagnosed?
In order to diagnose Nodal Marginal Zone Lymphoma, one should exclude malignancy in spleen and other parts of the body. The diagnosis is performed by obtaining biopsy samples from the affected region and examining them under a microscope to detect the cancerous cells. Other methods to aid in the study may include:
- A thorough physical examination and a complete medical history, which is very important
- Blood tests that may include:
- Complete blood cell count (CBC) blood test
- Absolute lymphocyte count on peripheral blood
- Liver function blood test (LFT)
- Lactate dehydrogenase (LDH) blood test
- Chemistry panel
- Serum calcium levels
- Serum albumin levels
- HIV testing
- Since the lymphoma involves the lymph nodes, biopsies of enlarged lymph nodes are taken and examined in a lab to determine if the cells are malignant or benign. The biopsies may be performed under general or local anesthesia. Normally, the entire lymph node is removed to help determine the subtype of lymphoma
- Biopsy from the affected area:
- A biopsy of the tumor is performed and sent to a laboratory for a pathological examination. A pathologist examines the biopsy under a microscope. After putting together clinical findings, special studies on tissues (if needed) and with microscope findings, the pathologist arrives at a definitive diagnosis. Examination of the biopsy under a microscope by a pathologist is considered to be gold standard in arriving at a conclusive diagnosis
- Biopsy specimens are studied initially using Hematoxylin and Eosin staining. The pathologist then decides on additional studies depending on the clinical situation
- Sometimes, the pathologist may perform special studies, which may include immunohistochemical stains, molecular testing, flow cytometric analysis and very rarely, electron microscopic studies, to assist in the diagnosis
- Radiological imaging may be performed to determine the extent of lymphoma in the body including:
- X-ray of the affected region
- Ultrasound scan of the affected region
- Computerized tomography (CT) scan of the affected region
- Vascular radiological studies
- Whole body bone scan
- Whole body CT-PET scans to determine how far the lymphoma has spread, by checking the size and metabolic rate (a reflection of uncontrolled growth) of lymph nodes, throughout the body. This can also help determine, if the cancer has spread to other organ systems
- Brain MRIs are used if neurological symptoms are present, which can help determine if the cancer has spread to the brain, or to tissues that cover the brain
- Bone marrow aspiration and biopsy is performed and sent to a laboratory for a pathological examination, to determine if the bone marrow is involved. Sometimes, the pathologist may perform special studies, which may include immunohistochemical stains, histochemical stains, molecular testing, and very rarely electron microscopic studies. However, a bone marrow biopsy is not needed in the early stages of the condition
- Flow cytometry to identify cells as they flow through an instrument, called a flow cytometer. Flow cytometry measures the number and percentage of cells in a blood sample, and cell characteristics such as size, shape, and the presence of biomarkers on the cell surface. This method helps to sub-classify the condition and also to detect residual levels of disease after treatment. This tool can help in diagnosing relapse and restart treatment as needed
- Fluorescence in situ hybridization (FISH): It is a test performed on the blood or bone marrow cells to detect chromosome changes (cytogenetic analysis) in blood cancer cells. The test helps in identifying genetic abnormalities that may not be evident with an examination of cells under a microscope
- Immunophenotyping to identify a specific type of cell in a sample, which can help determine the best treatment course to be followed
- Polymerase chain reaction (PCR): It is used to measure the presence of certain biomarkers in blood or bone marrow cells. The test is ultrasensitive and detects extremely low amounts of biomarkers remaining in blood, which can be missed by cytogenetic methods, such as FISH, karyotype, or flow cytometry. PCR allows a more sensitive follow-up of patients in remission and can help determine whether additional treatment is necessary
- GI endoscopy: It may be performed to assess the extent of tumor spread
- Multigated acquisition (MUGA) scan or echocardiography to identify cardiotoxicity as a result of chemotherapy
- Lumbar puncture to determine if the brain is involved
- In addition, the cerebrospinal spinal fluid (CSF) may be collected by inserting a needle in the spine and subjected to microscopic, flow cytometric, PCR, and biochemical analysis, to diagnose central nervous system (CNS) involvement, if any
- Exploratory laparoscopy (diagnostic laparoscopy) may be required, if gastrointestinal symptoms are present. In this procedure, the abdomen is examined using a minimally-invasive technique, and a tissue biopsy and tissue for culture obtained. Minimally-invasive approaches help decrease complications and the length of stay at the hospital. A diagnostic laparoscopy is also helpful in staging of the tumor. Nevertheless, this procedure is not very much used
- Differential diagnoses, to eliminate other tumor types are often considered, before arriving at a definitive diagnosis
- It is observed that between 50-60% of NMZL cases are diagnosed by or after stage 2
Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.
What are the possible Complications of Nodal Marginal Zone Lymphoma?
The complications due to Nodal Marginal Zone Lymphoma may include:
- Involvement to local and distant organs: It can spread from the lymph nodes to other parts of the body, resulting in loss of function of the organ/area to which the cancer has spread
- Recurrence of the lymphoma
- Weakened immune system (or immunosuppression) can be a complication, which can become more severe during treatment. Due to this, individuals are more vulnerable to infections; there is an increased risk of developing serious complications from such infections
- If the condition spreads to the brain and central nervous system, it can give rise to:
- Inflammation of the meninges or brain (that can be lethal)
- Vision changes
- Facial numbness
- If the abdomen is affected, it can cause intestinal obstruction that results in urine outflow obstruction and kidney damage
- Blood loss may occur due to frequent or heavy bleeding, giving rise to severe anemia
- Complications that may arise from underlying disorders, if any
Note: In general, individuals in this group do not have underlying autoimmune disorders or infections.
There may be complications related to chemotherapy used in treating the condition, which may include:
- Side effects such as dizziness, vomiting, appetite loss, mouth ulcers, and hair loss
- By damaging healthy cells, the individual is more open or vulnerable to secondary infections
- The treatment can also cause infertility in men and women. Hence, measures to protect the individual’s fertility must be considered, before starting chemotherapy
- Tumor lysis syndrome: This can occur due to chemotherapy treatment and can result in kidney failure, if not recognized promptly
How is Nodal Marginal Zone Lymphoma Treated?
Once a definitive diagnosis of Nodal Marginal Zone Lymphoma has been made, staging is used to describe how far the cancer has spread. The stage can help describe:
- How many lymph nodes are affected
- Their locations in the body
- And, if other organs are being affected
Staging is important because different treatment regimens are necessary, depending on the progression of the lymphoma. The stages of NMZL include:
- Stage 1: One group of lymph nodes are affected
- Stage 2: Two or more groups of lymph nodes on one side of the diaphragm are affected
- Stage 3: Lymph nodes on both sides of the diaphragm are affected
- Stage 4: The condition involves tissues other than lymphoid tissues such as spleen, liver, and bone marrow
For individuals who are asymptomatic, a ‘wait and watch’ approach is generally considered by the healthcare provider. In individuals with significant signs and symptoms, a combination of treatment measures may be effectively used to treat the condition. The treatment also depends upon the stage, overall health, age, and type of lymphoma.
It may involve the following:
- Chemotherapy: This approach uses a combination of drugs to kill the cancerous cells and can be used in patients, for all stages of the cancer
- There can be severe side effects including fatigue, nausea, hair loss, anemia, high risk of infection, and drug-specific reactions
- Many T-cell lymphomas can be resistant to chemotherapy. It can also damage healthy cells
- Chemotherapy can be administered as a pill, liquid, shot, or intravenously
Note: Men and women in child-bearing age would greatly benefit from counseling regarding fertility issues. Some chemotherapy agents can cause infertility in both men and women. There can be permanent damage to the testicles and ovaries, harming their ability to produce sperms or ova. In men, sperm banking can be considered before initiating therapy. In women, in many cases, due to urgency of starting chemotherapy, it is often difficult to perform ovum banking. However, if there is sufficient time prior to chemotherapy, ovum banking may be performed. The healthcare provider may help assess the risk-benefit analysis, depending upon each individual’s specific circumstances.
- Radiation: Radiation therapy is the use of high-energy radiation waves to kill cancer cells, by destroying their DNA
- This treatment modality is generally used for early stage lymphomas. It is most commonly used in combination with chemotherapy
- The radiation may be administered by a machine placed outside the body, or by placing a radioactive material inside the body
- The side effects of radiation therapy include nausea, vomiting, fatigue, pain, risk of cancer later in life, and risk of heart disease
- Radiation can damage healthy cells in addition to cancer cells, causing further complications
- Surgery: After initial biopsies to diagnose the condition, surgery is a very uncommon treatment option, because lymphomas are systemic and might have already spread to more than one lymph node in most patients. Under such circumstances, removing all the affected lymph nodes would be extremely difficult
- Intrathecal chemotherapy, if there is an involvement of the brain
- Supportive treatment: Steroids, blood transfusions, anti-nausea medications, and antibiotics, may be used as supportive therapy. In combination with other treatment measures, these can help combat the symptoms of immunodeficiency, on a case-by-case basis
If Nodal Marginal Zone Lymphoma is not fully responsive to treatment, or if the chance of recurrence is high, then bone marrow transplantation or stem cell transplantation can be considered.
- Bone marrow transplantation: Typically systemic cases may be treated by administering high doses of chemotherapy or radiotherapy. But, high doses of chemotherapy drugs will also damage the bone marrow, preventing it from making any blood cells. Hence, before starting high-dose chemotherapy, the physicians may take out some of the patient’s bone marrow and freeze/preserve it. Collecting the bone marrow is called a bone marrow harvest. The bone marrow is then stored. After high dose chemotherapy or radiation, the bone marrow is thawed and injected back into patient through a drip (transfusion). This is called an autologous bone marrow transplant. Sometimes bone marrow donated by another matching person (usually a brother or sister) is used, if the condition recurs following transplant using one’s own cell. This is called as allogeneic bone marrow transplant
- Stem cell transplantation: This procedure is similar to bone marrow transplantation and involves the transplantation of healthy blood-forming stem cells into the body. The procedure is also called hematopoietic progenitor cell transplantation. Stem cells can be collected from the bone marrow, circulating (peripheral) blood, and umbilical cord blood. It may either involve an autologous stem cell transplantation, where stem cells are harvested from individuals before treatment and transplanted back into the patient after treatment, or involve an allogeneic stem cell transplantation, where stem cells donated by another matching person (usually a brother or sister) is used, if the condition recurs after stem cell transplant using one’s own cell. This is called as allogeneic stem cell transplant
Note: Allogeneic bone marrow and allogeneic stem cell transplants may have more side effects and complications, and this treatment may not be suitable for every individual. If allogeneic transplants come from a healthy donor with no malignant cells, then the chances of recurrence of the condition may be reduced.
- In order to prevent infections because the immune system is weakened by NMZL or by its treatment, the patient is kept in an isolated ward and treated with appropriate antibiotics
- Nowadays, targeted therapies are being developed, that can selectively kill the lymphoma/leukemia cells. Many of them are in the stage of clinical trials
- Clinical trials: There may be some newer treatment options, currently on clinical trials, which can be considered for some patients depending on their respective risk factors
Your healthcare provider will determine the best course of treatment depending on your individual circumstances. Also, follow-up care with regular screening and check-ups are important post-treatment.
How can Nodal Marginal Zone Lymphoma be Prevented?
Presently, the cause of Nodal Marginal Zone Lymphoma is unknown, and there are no known methods to prevent its formation. Eliminating certain risk factors may help in avoiding the condition.
- Healthy diet and exercise, as well as avoidance of unnecessary exposure to chemicals, may help decrease its risk
- Avoidance or cessation of smoking
- Undertaking appropriate and prompt treatment of any viral infection or other disorders
- Promptly addressing the cause of concern of immunodeficiency
- Using appropriate protective gear while working with x-rays and other radioactive source
- In order to avoid a relapse, or be prepared for a recurrence, the entire diagnosis, treatment process, drugs administered, etc. should be well-documented and follow-up measures initiated
Regular medical screening at periodic intervals with blood tests, scans, and physical examinations, are mandatory. Often several years of active vigilance are crucial and necessary.
What is the Prognosis of Nodal Marginal Zone Lymphoma? (Outcomes/Resolutions)
- Nodal Marginal Zone Lymphoma is a slow-growing malignancy with a generally good prognosis. Usually lymphomas in this subset do not recur after treatment
- The prognosis depends upon a set of several factors, which include:
- Stage of tumor: With lower-stage tumors, when the tumor is confined to site of origin, the prognosis is usually excellent with appropriate therapy. In higher-stage tumors, such as tumors with metastasis, the prognosis is poor
- Overall health of the individual: Individuals with overall excellent health have better prognosis compared with those with poor health
- Age of the individual: Older individuals generally have poorer prognosis than younger individuals
- The size of the tumor: Individuals with small-sized tumors fare better than those with large-sized tumors
- Individuals with bulky disease have a poorer prognosis
- Involvement of vital organs may complicate the condition
- The surgical respectability of the tumor (meaning, if the tumor can be removed completely) - it is a rare option
- Whether the tumor is occurring for the first time, or is a recurrent tumor. Recurring tumors have worse prognosis compared to tumors that do not recur
- Response to treatment: Tumors that respond to treatment have better prognosis compared to tumors that do not respond to treatment
- Progression of the condition makes the outcome worse (progressive NMZL)
- An early diagnosis and prompt treatment of the tumor generally yields better outcomes than a late diagnosis and delayed treatment
- The combination chemotherapy drugs used, may have some severe side effects (such as cardio-toxicity). This chiefly impacts the elderly adults, or those who are already affected by other medical conditions. Tolerance to the chemotherapy sessions is a positive influencing factor
- Progression to bone marrow failure is usually associated with short survival
Additional and Relevant Useful Information for Nodal Marginal Zone Lymphoma:
- Monocytoid B-Cell Lymphoma is a term that is sometimes used to denote Nodal Marginal Zone Lymphoma
- Treatment for NMZL can cause physical and emotional distress; supportive care and encouragement, help positively and can bring a measure of relief to the patients
The following article link will help you understand leukemia and lymphoma (blood cancer):
What are some Useful Resources for Additional Information?
Leukemia & Lymphoma Society (LLS)
1311 Mamaroneck Ave., Suite 310 White Plains, NY 10605
Phone: (914) 949-5213
Toll-Free: (800) 955-4572
Fax: (914) 949-6691
National Cancer Institute (NCI)
U.S. National Institutes of Health
Public Inquiries Office
Building 31, Room 10A03
31 Center Drive, MSC 8322 Bethesda, MD 20892-2580
Phone: (301) 435-3848
Toll-Free: (800) 422-6237
TTY: (800) 332-8615
American Cancer Society (ACS)
1599 Clifton Road, NE Atlanta, GA 30329-4251
Toll-Free: (800) 227-2345
TTY: (866) 228-4327
American Academy of Dermatology
930 E. Woodfield Road Schaumburg, IL 60173
Phone: (866) 503-SKIN (7546)
Fax: (847) 240-1859
References and Information Sources used for the Article:
http://www.lymphoma.org/site/pp.asp?c=bkLTKaOQLmK8E&b=6300153 (accessed on 02/05/16)
http://www.macmillan.org.uk/Cancerinformation/Cancertypes/Lymphomanon-Hodgkin/TypesofNHL/DiffuselargeB-cell.aspx#DynamicJumpMenuManager_6_Anchor_3 (accessed on 02/05/16)
Lennert, K. (2013). Histopathology of non-Hodgkin’s lymphomas: based on the Kiel classification. Springer-Verlag.
Adler, E. M. (2005). Living with Lymphoma: A Patient's Guide. Johns Hopkins University Press.
Adler, N. E., & Page, A. E. (Eds.). (2008). Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. National Academies Press.
Carter, J. B., Goyal, A., & Duncan, L. M. (Eds.). (2015). Atlas of Cutaneous Lymphomas: Classification and Differential Diagnosis. Springer.
Helpful Peer-Reviewed Medical Articles:
Miranda, R. N., Khoury, J. D., & Medeiros, L. J. (2013). Nodal Marginal Zone Lymphoma. In Atlas of Lymph Node Pathology (pp. 195-198). Springer New York.
Angelopoulou, M. K., Kalpadakis, C., Pangalis, G. A., Kyrtsonis, M. C., & Vassilakopoulos, T. P. (2014). Nodal marginal zone lymphoma. Leukemia & lymphoma, 55(6), 1240-1250.
Kimby, E. K. (2013). Nodal Marginal Zone Lymphoma. In Lymphoma (pp. 137-142). Humana Press.
Stary, S., Vinatzer, U., Müllauer, L., Raderer, M., Birner, P., & Streubel, B. (2013). t (11; 14)(q23; q32) involving IGH and DDX6 in nodal marginal zone lymphoma. Genes, Chromosomes and Cancer, 52(1), 33-43.
Spina, V., Khiabanian, H., Bruscaggin, A., Messina, M., Monti, S., Holmes, A. B., ... & Tabbò, F. (2014). The Coding Genome of Nodal Marginal Zone Lymphoma Reveals Recurrent Molecular Alterations of PTPRD and Other Jak/Stat Signaling Genes. Blood, 124(21), 705-705.
van den Brand, M., van der Velden, W. J., Diets, I. J., Ector, G. I., de Haan, A. F., Stevens, W. B., ... & van Krieken, H. J. (2015). Clinical features of patients with nodal marginal zone lymphoma compared to follicular lymphoma: similar presentation, but differences in prognostic factors and rate of transformation. Leukemia & lymphoma, 1-8.
Camacho, F. I., Algara, P., Mollejo, M., García, J. F., Montalbán, C., Martínez, N., ... & Piris, M. A. (2003). Nodal marginal zone lymphoma: a heterogeneous tumor: a comprehensive analysis of a series of 27 cases. The American journal of surgical pathology, 27(6), 762-771.
Arribas, A. J., Campos-Martín, Y., Gómez-Abad, C., Algara, P., Sánchez-Beato, M., Rodriguez-Pinilla, M. S., ... & Mollejo, M. (2012). Nodal marginal zone lymphoma: gene expression and miRNA profiling identify diagnostic markers and potential therapeutic targets. Blood, 119(3), e9-e21.
Arcaini, L., Lucioni, M., Boveri, E., & Paulli, M. (2009). Nodal marginal zone lymphoma: current knowledge and future directions of an heterogeneous disease. European journal of haematology, 83(3), 165-174.