Compendium of Cancer Genome Aberrations

Extranodal NK/T-cell lymphoma

Revision as of 11:26, 19 August 2024 by Teodora.Popa (talk | contribs)


Haematolymphoid Tumours (5th ed.)

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Primary Author(s)*

Teodora Popa, MD, Queen's University

Amanda Xu, MD, Queen's University

Cancer Category / Type

Mature T-cell and NK-cell neoplasms

Cancer Sub-Classification / Subtype

EBV-positive T-cell and NK-cell neoplasms

Definition / Description of Disease

Extranodal NK/T-cell lymphoma (ENKTL) is a distinct entity in the 5th edition World Health Organization (WHO) classification system. It is referred to as "extranodal NK/T-cell lymphoma, nasal type" in the 2016 WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues revised 4th edition[1].

  • ENKTL is a lymphoma of NK or T-cell lineage strongly associated with Epstein-Barr virus[2].
  • It is a destructive angiocentric disease characterized by vascular destruction and necrosis[3].
  • It can be clinically divided into nasal and non-nasal types, the latter most often occurring in the skin and intestinal tract[1][2].
  • The lineage (NK or T-cell) has no clinical significance[4].
  • The differential diagnosis includes sinonasal carcinomas and other lymphomas of the nasal cavity, such as diffuse large B-cell lymphoma[5].

Synonyms / Terminology

Extranodal NK/T-cell lymphoma, nasal type; EBV-positive extranodal NK/T-cell lymphoma; angiocentric lymphoma (not recommended); lethal midline granuloma (historical)

Epidemiology / Prevalence

ENKTL is most prevalent in East Asia and Latin America. It represents less than 1% of non-Hodgkin lymphomas in the United States, with the highest incidence among Asian Pacific Islanders and Hispanic populations[6].

Clinical Features

Common clinical presentations of nasal-type ENKTL include nasal mass, obstruction, and bleeding. Patients with abdominal involvement may present with abdominal pain, gastrointestinal (GI) bleed, or perforation[7]. The presence of B symptoms is associated with higher clinical stage[8].

Signs and Symptoms Nasal mass, nasal obstruction, nasal bleeding

Hoarseness, dysphagia, halitosis, airway obstruction, dysphonia

Abdominal pain, GI bleeding, bowel perforation

B symptoms (fever, weight loss, night sweats)

Laboratory Findings No specific findings

Cytopenias

Sites of Involvement

Most cases of ENKTL are nasal type, meaning they involve the upper aerodigestive tract. Extranasal ENKTL may involve the skin, testis, and gastrointestinal tract[7]. Bone marrow involvement is uncommon[9].

Morphologic Features

  • Diffuse lymphomatous infiltrate composed of small, medium, or large and anaplastic cells (or a mix of small and large cells). The cells have irregularly folded nuclei and moderate pale cytoplasm.
  • Loss of mucosal glands.
  • Angiocentric and angiodestructive growth pattern.
  • Coagulative necrosis and apoptosis.
  • Mitotic figures.

Pitfalls:

  • Mucosal ulceration and superimposed inflammation can mimic an inflammatory process, particularly in less aggressive cases[10].
  • Pseudoepitheliomatous hyperplasia of the overlying mucosal epithelium can mimic squamous cell carcinoma[11][12].


***Amanda, do you know if we have any good cases we could scan and add photos of?

Immunophenotype

The majority of cases are positive for cytoplasmic CD3ε, CD2, granzyme B, and TIA-1. Most ENKTLs are of NK-lineage and express CD56. Cases of T-lineage express T-cell receptor (TCR) and show clonal TCR gene rearrangements. All cases are EBV positive by in situ hybridization for Epstein-Barr virus-encoded small RNA (EBER). Other markers that may be expressed include HLA-DR, CD25, pSTAT3, CXCL13, IRF4/MUM1, CD16, Fas, FasL, MATK, and CD30[13][14][15][16][17][18][19].

Finding Marker
Positive (universal) CD2, CD56, cytoplasmic CD3ε, cytotoxic markers (TIA-1, granzyme B, perforin)

EBER / EBV

Positive (subset) TCR αβ/γδ, HLA-DR, CD25, pSTAT3, CXCL13, IRF4/MUM1, CD16, Fas, FasL, MATK, CD30
Negative (universal) CD4, CD8
Negative (subset) Surface CD3 (subset of T-cell lineage)[7]

Chromosomal Rearrangements (Gene Fusions)

No specific chromosomal translocation has been identified in ENKTL.

Chromosomal Rearrangement Genes in Fusion (5’ or 3’ Segments) Pathogenic Derivative Prevalence Diagnostic Significance (Yes, No or Unknown) Prognostic Significance (Yes, No or Unknown) Therapeutic Significance (Yes, No or Unknown) Notes
N/A N/A N/A N/A N/A N/A N/A N/A

Individual Region Genomic Gain / Loss / LOH

ENKTL shows recurring deletion at 6q21-25[20][21].

Other less common chromosomal alterations include gain of 1p, 2q, 6p, 10q, 11q, 12q, 13q, 17q, 19p, 20q, and Xp; and loss of 1p36, 2p16, 4q12, 4q31-32, 5p14, 5q34-35, 6q13-14, 6q16-27, 11q22-23, 12q, 13q12-14, 13q14-34, 17p13, and entire chromosome X[22][23][24][25][26].

Chr # Gain / Loss / Amp / LOH Minimal Region Genomic Coordinates [Genome Build] Minimal Region Cytoband Diagnostic Significance (Yes, No or Unknown) Prognostic Significance (Yes, No or Unknown) Therapeutic Significance (Yes, No or Unknown) Notes
6 Loss 6q21-25 Unknown Unknown Unknown This locus harbours multiple candidate tumour suppressor genes including ATG5, AIM1, PRDM1, PTPRK, HACE1, and FOXO3[27][28][29].

Characteristic Chromosomal Patterns

Chromosomal Pattern Diagnostic Significance (Yes, No or Unknown) Prognostic Significance (Yes, No or Unknown) Therapeutic Significance (Yes, No or Unknown) Notes
Isochromosome 6p[30] Unknown Unknown Unknown N/A
Isochromosome 7q[31] Unknown Unknown Unknown N/A

Gene Mutations (SNV / INDEL)

Recurrent mutations have been identified in several genes, listed below. Currently, molecular testing for these alterations is not routinely performed.

Gene; Genetic Alteration Presumed Mechanism (Tumor Suppressor Gene [TSG] / Oncogene / Other) Prevalence (COSMIC / TCGA / Other) Concomitant Mutations Mutually Exclusive Mutations Diagnostic Significance (Yes, No or Unknown) Prognostic Significance (Yes, No or Unknown) Therapeutic Significance (Yes, No or Unknown) Notes
JAK3[32][33] Oncogene 35.4%[32] Pan-JAK and selective JAK3 inhibitors have been suggested as potential therapeutic options[32][34].
STAT3[35][36][37] 26%[37] STAT3 inhibitor may have potential therapeutic benefit in patients with STAT3 activating mutation[38].
STAT5B[35][36]
PTPRK[29] Other (acts on JAK/STAT pathway; underexpression leads to STAT3 activation[29])
KIT[29] Oncogene
CTNNB1[29] Oncogene
TP53[35] Tumor suppressor gene 24-62%[39][40] Yes, associated with advanced stage disease[39].
MGA[35] Tumor suppressor gene
PRDM1[41][28][42] Tumor suppressor gene
ATG5[41] Tumor suppressor gene
AIM1[41] Tumor suppressor gene
FOXO3[41][28] Tumor suppressor gene
HACE1[41][43] Tumor suppressor gene
RAS[40] Oncogene
MYC Oncogene

Note: A more extensive list of mutations can be found in cBioportal (https://www.cbioportal.org/), COSMIC (https://cancer.sanger.ac.uk/cosmic), ICGC (https://dcc.icgc.org/) and/or other databases. When applicable, gene-specific pages within the CCGA site directly link to pertinent external content.

Epigenomic Alterations

A 2015 study by Lu, et al uncovered recurrent mutations in the RNA helicase gene DDX3X and other epigenetic modifiers including KMT2D (MLL2), ARID1A, EP300, and ASXL3[35].

Similarly, a 2015 study by Lee, et al reported that histone modification-related genes, including BCOR and KMT2D (MLL2), accounted for 38.2% of 34 ENKTL samples by next-generation sequencing[37].

Genes and Main Pathways Involved

Gene; Genetic Alteration Pathway Pathophysiologic Outcome
JAK3, STAT3, and STAT5B; Activating mutations JAK/STAT pathway Increased cell growth and proliferation

Genetic Diagnostic Testing Methods

Not routinely performed. Select cases may require TCR gene rearrangement studies.

Familial Forms

N/A

Additional Information

N/A

Links

5th edition World Health Organization (WHO) classification system

References

  1. ↑ 1.0 1.1 Chan J. K. C., et al., (2017). Extranodal NK/T-cell lymphoma, nasal type, in World Health Organization Classification of Tumours of Haematopoietic and Lymphoid Tissues, Revised 4th edition. Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA, Stein H, Thiele J, Arber DA, Hasserjian RP, Le Beau MM, Orazi A, and Siebert R, Editors. Revised 4th Edition. IARC Press: Lyon, France, p.368-371.
  2. ↑ 2.0 2.1 Jaffe, E. S.; et al. (1999-01). "Extranodal peripheral T-cell and NK-cell neoplasms". American Journal of Clinical Pathology. 111 (1 Suppl 1): S46–55. ISSN 0002-9173. PMID 9894469. Check date values in: |date= (help)
  3. ↑ Aviles, A.; et al. (1992). "Angiocentric T-cell lymphoma of the nose, paranasal sinuses and hard palate". Hematological Oncology. 10 (3–4): 141–147. doi:10.1002/hon.2900100303. ISSN 0278-0232. PMID 1398510.
  4. ↑ Wang, Hua; et al. (2021-09). "NK-/T-cell lymphomas". Leukemia. 35 (9): 2460–2468. doi:10.1038/s41375-021-01313-2. ISSN 1476-5551. PMC 8410593 Check |pmc= value (help). PMID 34117356 Check |pmid= value (help). Check date values in: |date= (help)
  5. ↑ Steele, Toby O.; et al. (2016-09). "Lymphoma of the nasal cavity and paranasal sinuses: A case series". American Journal of Rhinology & Allergy. 30 (5): 335–339. doi:10.2500/ajra.2016.30.4347. ISSN 1945-8932. PMID 27657899. Check date values in: |date= (help)
  6. ↑ Haverkos, Bradley M.; et al. (2016-12). "Extranodal NK/T-cell lymphoma, nasal type (ENKTL-NT): An update on epidemiology, clinical presentation, and natural history in North American and European cases". Current hematologic malignancy reports. 11 (6): 514–527. doi:10.1007/s11899-016-0355-9. ISSN 1558-8211. PMC 5199232. PMID 27778143. Check date values in: |date= (help)
  7. ↑ 7.0 7.1 7.2 Thida AM, Gohari P. Extranodal NK-Cell Lymphoma. [Updated 2023 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559207/
  8. ↑ Takahara, Miki; et al. (2021-06-25). "Extranodal NK/T-Cell Lymphoma, Nasal Type: Genetic, Biologic, and Clinical Aspects with a Central Focus on Epstein-Barr Virus Relation". Microorganisms. 9 (7): 1381. doi:10.3390/microorganisms9071381. ISSN 2076-2607. PMC 8304202 Check |pmc= value (help). PMID 34202088 Check |pmid= value (help).
  9. ↑ Wong, K. F.; et al. (2001-02). "Bone marrow involvement by nasal NK cell lymphoma at diagnosis is uncommon". American Journal of Clinical Pathology. 115 (2): 266–270. doi:10.1309/E5PR-6A9R-Q02N-8QVW. ISSN 0002-9173. PMID 11211616. Check date values in: |date= (help)
  10. ↑ Devins, K., Schuster, S.J., Caponetti, G.C. et al. Rare case of low-grade extranodal NK/T-cell lymphoma, nasal type, arising in the setting of chronic rhinosinusitis and harboring a novel N-terminal KIT mutation. Diagn Pathol 13, 92 (2018). https://doi.org/10.1186/s13000-018-0765-1
  11. ↑ Ling, Yi-Hong; et al. (2015-09). "Pseudoepitheliomatous hyperplasia mimicking invasive squamous cell carcinoma in extranodal natural killer/T-cell lymphoma: a report of 34 cases". Histopathology. 67 (3): 404–409. doi:10.1111/his.12656. ISSN 1365-2559. PMID 25619876. Check date values in: |date= (help)
  12. ↑ Xiang, Chun-Xiang; et al. (2019-07). "Laryngeal Extranodal Nasal-type Natural Killer/T-cell Lymphoma: A Clinicopathologic Study of 31 Cases in China". The American Journal of Surgical Pathology. 43 (7): 995–1004. doi:10.1097/PAS.0000000000001266. ISSN 1532-0979. PMID 31045893. Check date values in: |date= (help)
  13. ↑ Li, Shaoying; et al. (2013-01). "Extranodal NK/T-cell lymphoma, nasal type: a report of 73 cases at MD Anderson Cancer Center". The American Journal of Surgical Pathology. 37 (1): 14–23. doi:10.1097/PAS.0b013e31826731b5. ISSN 1532-0979. PMID 23232851. Check date values in: |date= (help)
  14. ↑ Jhuang, Jie-Yang; et al. (2015-02). "Extranodal natural killer/T-cell lymphoma, nasal type in Taiwan: a relatively higher frequency of T-cell lineage and poor survival for extranasal tumors". Human Pathology. 46 (2): 313–321. doi:10.1016/j.humpath.2014.11.008. ISSN 1532-8392. PMID 25554090. Check date values in: |date= (help)
  15. ↑ Pongpruttipan, Tawatchai; et al. (2012-04). "Extranodal NK/T-cell lymphoma, nasal type, includes cases of natural killer cell and αβ, γδ, and αβ/γδ T-cell origin: a comprehensive clinicopathologic and phenotypic study". The American Journal of Surgical Pathology. 36 (4): 481–499. doi:10.1097/PAS.0b013e31824433d8. ISSN 1532-0979. PMID 22314189. Check date values in: |date= (help)
  16. ↑ Jaffe, E. S.; et al. (1996-01). "Report of the Workshop on Nasal and Related Extranodal Angiocentric T/Natural Killer Cell Lymphomas. Definitions, differential diagnosis, and epidemiology". The American Journal of Surgical Pathology. 20 (1): 103–111. doi:10.1097/00000478-199601000-00012. ISSN 0147-5185. PMID 8540601. Check date values in: |date= (help)
  17. ↑ Ohshima, K.; et al. (1997-11). "Nasal T/NK cell lymphomas commonly express perforin and Fas ligand: important mediators of tissue damage". Histopathology. 31 (5): 444–450. doi:10.1046/j.1365-2559.1997.2880887.x. ISSN 0309-0167. PMID 9416485. Check date values in: |date= (help)
  18. ↑ Takata, Katsuyoshi; et al. (2015-01). "Primary cutaneous NK/T-cell lymphoma, nasal type and CD56-positive peripheral T-cell lymphoma: a cellular lineage and clinicopathologic study of 60 patients from Asia". The American Journal of Surgical Pathology. 39 (1): 1–12. doi:10.1097/PAS.0000000000000312. ISSN 1532-0979. PMID 25188863. Check date values in: |date= (help)
  19. ↑ Kuo, Tseng-Tong; et al. (2004-10). "Nasal NK/T cell lymphoma in Taiwan: a clinicopathologic study of 22 cases, with analysis of histologic subtypes, Epstein-Barr virus LMP-1 gene association, and treatment modalities". International Journal of Surgical Pathology. 12 (4): 375–387. doi:10.1177/106689690401200410. ISSN 1066-8969. PMID 15494863. Check date values in: |date= (help)
  20. ↑ Wong, K. F.; et al. (1997-09). "Identification of del(6)(q21q25) as a recurring chromosomal abnormality in putative NK cell lymphoma/leukaemia". British Journal of Haematology. 98 (4): 922–926. doi:10.1046/j.1365-2141.1997.3223139.x. ISSN 0007-1048. PMID 9326190. Check date values in: |date= (help)
  21. ↑ Ohshima, Koichi; et al. (2002-02). "Analysis of chromosome 6q deletion in EBV-associated NK cell leukaemia/lymphoma". Leukemia & Lymphoma. 43 (2): 293–300. doi:10.1080/10428190290006062. ISSN 1042-8194. PMID 11999560. Check date values in: |date= (help)
  22. ↑ Nakashima, Yasuhiro; et al. (2005-11). "Genome-wide array-based comparative genomic hybridization of natural killer cell lymphoma/leukemia: different genomic alteration patterns of aggressive NK-cell leukemia and extranodal Nk/T-cell lymphoma, nasal type". Genes, Chromosomes & Cancer. 44 (3): 247–255. doi:10.1002/gcc.20245. ISSN 1045-2257. PMID 16049916. Check date values in: |date= (help)
  23. ↑ Siu, L. L.; et al. (2000-12). "Consistent patterns of allelic loss in natural killer cell lymphoma". The American Journal of Pathology. 157 (6): 1803–1809. doi:10.1016/S0002-9440(10)64818-3. ISSN 0002-9440. PMC 1885756. PMID 11106552. Check date values in: |date= (help)
  24. ↑ Siu, L. L.; et al. (1999-11). "Comparative genomic hybridization analysis of natural killer cell lymphoma/leukemia. Recognition of consistent patterns of genetic alterations". The American Journal of Pathology. 155 (5): 1419–1425. doi:10.1016/S0002-9440(10)65454-5. ISSN 0002-9440. PMC 1866965. PMID 10550295. Check date values in: |date= (help)
  25. ↑ Wong, K. F.; et al. (1999-07). "Cytogenetic abnormalities in natural killer cell lymphoma/leukaemia--is there a consistent pattern?". Leukemia & Lymphoma. 34 (3–4): 241–250. doi:10.3109/10428199909050949. ISSN 1042-8194. PMID 10439361. Check date values in: |date= (help)
  26. ↑ Ko, Y. H.; et al. (2001-04-15). "Comparative genomic hybridization study of nasal-type NK/T-cell lymphoma". Cytometry. 46 (2): 85–91. doi:10.1002/cyto.1069. ISSN 0196-4763. PMID 11309817.
  27. ↑ Iqbal, J.; et al. (2009-06). "Genomic analyses reveal global functional alterations that promote tumor growth and novel tumor suppressor genes in natural killer-cell malignancies". Leukemia. 23 (6): 1139–1151. doi:10.1038/leu.2009.3. ISSN 1476-5551. PMID 19194464. Check date values in: |date= (help)
  28. ↑ 28.0 28.1 28.2 Karube, Kennosuke; et al. (2011-09-22). "Identification of FOXO3 and PRDM1 as tumor-suppressor gene candidates in NK-cell neoplasms by genomic and functional analyses". Blood. 118 (12): 3195–3204. doi:10.1182/blood-2011-04-346890. ISSN 1528-0020. PMID 21690554.
  29. ↑ 29.0 29.1 29.2 29.3 29.4 Chen, Yun-Wen; et al. (2015-03-05). "Receptor-type tyrosine-protein phosphatase κ directly targets STAT3 activation for tumor suppression in nasal NK/T-cell lymphoma". Blood. 125 (10): 1589–1600. doi:10.1182/blood-2014-07-588970. ISSN 1528-0020. PMID 25612622.
  30. ↑ Tien, H. F.; et al. (1997-06). "Clonal chromosomal abnormalities as direct evidence for clonality in nasal T/natural killer cell lymphomas". British Journal of Haematology. 97 (3): 621–625. doi:10.1046/j.1365-2141.1997.752711.x. ISSN 0007-1048. PMID 9207410. Check date values in: |date= (help)
  31. ↑ Feldman, Andrew L.; et al. (2008-08). "Incidence of TCR and TCL1 gene translocations and isochromosome 7q in peripheral T-cell lymphomas using fluorescence in situ hybridization". American Journal of Clinical Pathology. 130 (2): 178–185. doi:10.1309/PNXUKA1CFJMVGCN1. ISSN 0002-9173. PMC 3625137. PMID 18628085. Check date values in: |date= (help)
  32. ↑ 32.0 32.1 32.2 Koo, Ghee Chong; et al. (2012-07). "Janus kinase 3-activating mutations identified in natural killer/T-cell lymphoma". Cancer Discovery. 2 (7): 591–597. doi:10.1158/2159-8290.CD-12-0028. ISSN 2159-8290. PMID 22705984. Check date values in: |date= (help)
  33. ↑ Bouchekioua, A.; et al. (2014-02). "JAK3 deregulation by activating mutations confers invasive growth advantage in extranodal nasal-type natural killer cell lymphoma". Leukemia. 28 (2): 338–348. doi:10.1038/leu.2013.157. ISSN 1476-5551. PMID 23689514. Check date values in: |date= (help)
  34. ↑ Nairismägi, M.-L.; et al. (2018-05). "Oncogenic activation of JAK3-STAT signaling confers clinical sensitivity to PRN371, a novel selective and potent JAK3 inhibitor, in natural killer/T-cell lymphoma". Leukemia. 32 (5): 1147–1156. doi:10.1038/s41375-017-0004-x. ISSN 1476-5551. PMC 5940653. PMID 29434279. Check date values in: |date= (help)
  35. ↑ 35.0 35.1 35.2 35.3 35.4 Jiang, Lu; et al. (2015-09). "Exome sequencing identifies somatic mutations of DDX3X in natural killer/T-cell lymphoma". Nature Genetics. 47 (9): 1061–1066. doi:10.1038/ng.3358. ISSN 1546-1718. PMID 26192917. Check date values in: |date= (help)
  36. ↑ 36.0 36.1 Küçük, Can; et al. (2015-01-14). "Activating mutations of STAT5B and STAT3 in lymphomas derived from γδ-T or NK cells". Nature Communications. 6: 6025. doi:10.1038/ncomms7025. ISSN 2041-1723. PMC 7743911 Check |pmc= value (help). PMID 25586472.
  37. ↑ 37.0 37.1 37.2 Lee, Seungbok; et al. (2015-07-10). "Genetic alterations of JAK/STAT cascade and histone modification in extranodal NK/T-cell lymphoma nasal type". Oncotarget. 6 (19): 17764–17776. doi:10.18632/oncotarget.3776. ISSN 1949-2553. PMC 4627344. PMID 25980440.
  38. ↑ Wang, Yali; et al. (2023-08). "Preclinical characterization of WB737, a potent and selective STAT3 inhibitor, in natural killer/T-cell lymphoma". MedComm. 4 (4): e284. doi:10.1002/mco2.284. ISSN 2688-2663. PMC PMC10274570 Check |pmc= value (help). PMID 37334274 Check |pmid= value (help). Check date values in: |date= (help)CS1 maint: PMC format (link)
  39. ↑ 39.0 39.1 Quintanilla-Martinez, L.; et al. (2001-12). "p53 Mutations in nasal natural killer/T-cell lymphoma from Mexico: association with large cell morphology and advanced disease". The American Journal of Pathology. 159 (6): 2095–2105. doi:10.1016/S0002-9440(10)63061-1. ISSN 0002-9440. PMC 1850589. PMID 11733360. Check date values in: |date= (help)
  40. ↑ 40.0 40.1 Hongyo, Tadashi; et al. (2005-02). "p53, K-ras, c-kit and beta-catenin gene mutations in sinonasal NK/T-cell lymphoma in Korea and Japan". Oncology Reports. 13 (2): 265–271. ISSN 1021-335X. PMID 15643509. Check date values in: |date= (help)
  41. ↑ 41.0 41.1 41.2 41.3 41.4 Huang, Yenlin; et al. (2013-03). "Molecular underpinning of extranodal NK/T-cell lymphoma". Best Practice & Research. Clinical Haematology. 26 (1): 57–74. doi:10.1016/j.beha.2013.04.006. ISSN 1532-1924. PMID 23768641. Check date values in: |date= (help)
  42. ↑ Küçük, Can; et al. (2011-12-13). "PRDM1 is a tumor suppressor gene in natural killer cell malignancies". Proceedings of the National Academy of Sciences of the United States of America. 108 (50): 20119–20124. doi:10.1073/pnas.1115128108. ISSN 1091-6490. PMC 3250125. PMID 22143801.
  43. ↑ Huang, Yenlin; et al. (2010-02-11). "Gene expression profiling identifies emerging oncogenic pathways operating in extranodal NK/T-cell lymphoma, nasal type". Blood. 115 (6): 1226–1237. doi:10.1182/blood-2009-05-221275. ISSN 1528-0020. PMC 2826234. PMID 19965620.

Notes

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