Peripheral T-cell lymphoma

Peripheral T-cell lymphoma is the most common type of T-cell lymphoma seen in adults in the United States. Clinical data were reviewed from 134 cases of peripheral T-cell lymphoma diagnosed in three centers. The median age of the patients was 57 years (range, 4-97 years), 59% were male, and 36 patients (27%) had a history of a preceding disorder of the immune system. The tumors were grouped histologically into large cell (43%), mixed large and small cell (40%), and small cell (17%). The stage at diagnosis was I (7%), II (21%), III (22%), and IV (50%). B symptoms were present in 57%. The most frequent sites of extranodal involvement were bone marrow (35%), skin (13%), and lung (11%). Eighty patients were treated with a multiagent chemotherapy regimen with proven curative potential in aggressive non-Hodgkin's lymphomas and the remainder of the patients received less intensive chemotherapy (36 patients), radiotherapy (nine patients), or no treatment (nine patients). Fifty percent of the intensively treated patients achieved complete remission and the actuarial 4-year survival was 45%. However, the 4-year, disease-free survival in patients with Stage IV disease was only 10%. Although peripheral T-cell lymphomas appeared similar in many ways to their B-cell counterparts, disease-free survival by stage was low and patients with Stage IV disease had an especially poor outlook.

Transformation of cutaneous T cell lymphoma to large cell lymphoma. A clinicopathologic and immunologic study

Some patients with cutaneous T cell lymphoma (CTCL) develop a high-grade, large-cell lymphoma associated with rapid deterioration of clinical status. This change in histologic appearance and clinical behavior of CTCL is similar to transformations of other hematopoietic and lymphoid neoplasms. From a group of 92 cases of CTCL, morphologic, immunologic and clinical features were studied in 17 cases of transformed CTCL. Transformation was noted, at presentation or subsequently, in either cutaneous or extracutaneous sites; remarkably, transformation was found at initial diagnosis of CTCL in 7 of 17 patients. T cell characteristics were maintained in all 17 cases of transformed CTCL; in 11 cases with complete phenotypes, there were 6 T-helper, 3 T-suppressor, and 2 aberrant T subtypes. The pre- and posttransformation phenotypes were similar in 3 of 7 cases tested over time (all T-helper); retention of T-suppressor phenotype was suggested in another case. T cell features were maintained in the other 3 cases, but the T subtypes were altered in 2 of these cases. Absent or diminished pan-T antigens (CD 5, CD 3, or UCHL1) were found in 9 of 17 cases. Leu-M1, Ki-1, or LN 2 antigens were expressed by transformed cells in 10 of 17 cases, often in patterns identical to Reed-Sternberg cells. Survival in patients with transformed CTCL was significantly shorter (median, 29 months) than in 44 CTCL patients without transformation (58 months, P = 0.015); survival after diagnosis of transformation was short (12 months). Patients with extracutaneous transformation had a shorter median survival after transformation (8 months) than those with transformation limited to skin (19 months). It is concluded that CTCL can transform morphologically to a large cell variant associated with aggressive behavior and shortened survival. Extracutaneous transformation apparently indicates a poorer prognosis than cutaneous transformation. Although transformed CTCL usually retains a T cell phenotype, some antigens are lost while other new antigens may be expressed. Recognition of transformed CTCL is facilitated by identification of the dysplastic cerebriform cell component, but often requires correlation of immunologic and clinical features.

A simplified plastic embedding and immunohistologic technique for immunophenotypic analysis of human hematopoietic and lymphoid tissues

Routine fixation and paraffin embedding destroys many hematopoietic and lymphoid differentiation antigens detected by flow cytometry or frozen section immunohistochemistry. On the other hand, morphologic evaluation is difficult in flow cytometric or frozen section studies. A simplified three-step plastic embedding system using acetone-fixed tissues embedded in glycol-methacrylate (GMA) resin has been found to provide both excellent morphologic and antigenic preservation. With our system, a wide variety of antigens are detected in plastic sections without trypsinization or prolonged embedding procedures; pan-B (CD19, CD22), pan-T (CD7, CD5, CD3, CD2), T-subset (CD4, CD8, CD1, CD25) markers as well as surface immunoglobulin and markers for myeloid and mononuclear-phagocyte cells are preserved. In summary, modifications of plastic embedding techniques used in this study simplify the procedure, apparently achieve excellent antigenic preservation, and facilitate evaluation of morphologic details in relation to immunocytochemical markers.

T4+ (helper phenotype) chronic lymphocytic leukemia: case report with liver failure and literature review

T-cell lymphomas and leukemias are a heterogeneous group of neoplasms found in each anatomic compartment of the T system (marrow, thymus, and various peripheral tissues) and that have varying phenotypic expressions. Histopathologic features of the thymic and peripheral T neoplasms do not fit into a clearly defined pattern, and clinical expressions of T neoplasms are likewise variable. This report describes a 60-year-old man with "chronic" lymphocytic leukemia of T4+ (helper) phenotype. Rapid deterioration in liver function, presumably due to tumor infiltration, was unexpected and has not previously been reported. The unusual clinical and pathologic features are reviewed in the context of T-cell neoplasms, particularly T4+ processes.

Malignant lymphomas of follicular center cell origin in man. VI. Large cleaved cell lymphoma

Between 1970 and 1986 61 patients with large cleaved cell lymphoma (LCCL) were observed and treated. Median age was 56, and there were slightly more women than men (ratio, 1.4:1). Forty-four cases (72%) had both a nodular and diffuse pattern; eight cases were nodular; nine cases were diffuse. Forty-three patients (70%) had Stage III or IV disease; four patients were Stage I (7%); 14 were Stage II (23%). Bone marrow was involved in 15 of 56 evaluable patients (27%). The median survival was 57 months. It was significantly shorter in symptomatic patients (median, 20 months) than in asymptomatic patients (median, 66 months; P = 0.002). Survival time was also shorter in Stage III and IV patients (median, 46 months) compared with Stage I and II patients (median, 100+ months; P = 0.032). Survival was independent of the disease pattern, marrow involvement, age, gender, and surface immunoglobulin heavy or light chain. Among Stage III and IV patients, survival was the same in patients who received therapy initially and in those who were treated expectantly. Among 10 advanced-stage patients who did not initially receive therapy, the median time to beginning therapy was 17 months; five patients received no therapy for 40 to 96 months. Among 14 advanced-stage patients receiving therapy regarded as curative in aggressive lymphoma, 50% experienced a complete remission (CR). However, unlike other aggressive large cell lymphomas, long-term, relapse-free survival was observed in only 9% of patients as the majority of CRs were associated with relapse rather than cure. Despite the fact that it is a large cell lymphoma, LCCL is best regarded as an indolent lymphoma.

Evaluation of the Coulter S-Plus IV three-part differential as a screening tool in a tertiary care hospital

The Coulter S-Plus IV separates leukocytes in peripheral blood by volume analysis into granulocytes, lymphocytes, and mononuclear cell fractions, the so-called three-part differential (3PD). White blood cell (WBC) counts, hemoglobin concentrations, platelet counts, 3PDs, and histograms were compared with smear differentials on 3,861 samples, including samples from oncology patients, to determine the predictive value of the Coulter parameters in detecting smear abnormalities. Results showed good correlation between the 3PD and smear differential for granulocytes and lymphocytes (correlation coefficients were 0.883 and 0.868, respectively) and poor correlation for mononuclear cells (0.492). No histogram region flag indicators were observed in the following samples: 15 of 40 samples with greater than or 1% blasts; 105 of 183 with greater than or 1 nucleated red blood cell (NRBC) per 100 WBCs; 65 of 113 with monocytosis greater than 1,600/microL (1.6 X 10(9)/L); 425 of 548 with greater than 2,000 bands/microL (2.0 X 10(9)/L); 84 of 112 with eosinophilia greater than 600/microL (0.6 X 10(9)L); and 88 of 149 with greater than 2% immature granulocytes. All samples with greater than 5% blasts were indicated by region flags and abnormal histograms. Oncology patient data were analyzed, yielding similar results. The authors established guidelines for using the Coulter 3PD data in their tertiary care laboratory to select samples that require smear evaluation.

Variable differentiation patterns of acute myelogenous leukaemia blasts in liquid suspension cultures

To study the ability of acute myelogenous leukaemia blasts to spontaneously differentiate in vitro, bone marrow and/or blood mononuclear cells from 63 patients with acute myelogenous leukaemia were incubated in liquid suspension cultures containing human serum, without addition of chemical inducers of differentiation. Cultures were examined weekly for disappearance or persistence of blasts, and for appearance of morphologically recognizable granulocytes and macrophages. Culture outcomes were extremely variable, ranging from lack of appearance of differentiated cells to complete disappearance of blasts with replacement by mature cells. In 50 cases an increase (25-185%) in the absolute number of differentiated cells in culture was noted during the culture period. Full differentiation was seen exclusively in cultures from 13/48 (27.1%) patients studied at diagnosis, as compared to 0/20 patients studied at relapse (P less than 0.01). The ability to fully or partially differentiate in culture was lost to a significant degree at relapse (13/20 patients) as compared to diagnosis (48/48 patients, P = 0.0001). At diagnosis full differentiation in culture was associated with a significantly higher remission rate than partial differentiation (89% versus 40%, P less than 0.02). Origination of mature cells from leukaemic rather than normal precursors was suggested by the appearance of Auer rods in mature cells in seven cases, by the correlation of types of differentiated cells seen in culture with the FAB class of leukaemia and by cytogenetic data in one case.

Increased levels of carboxyhemoglobin and serum iron as an indicator of increased red cell turnover in preeclampsia

Patients with severe preeclampsia are reported to have microangiopathic hemolytic anemia. This study demonstrates that increased red cell turnover with heme catabolism is also common in mild preeclampsia. Heme catabolism results in equimolar production of carboxyhemoglobin, iron, and bilirubin. A concomitant rise in these constituents of venous blood would support this hypothesis. Patients with antepartum preeclampsia had mean carboxyhemoglobin concentrations (2.72% total hemoglobin) greater than those of control patients (0.65%) (p less than 0.001) and serum iron concentrations (98.5 micrograms/dl) greater than those of control patients (66.1 micrograms/dl) (p less than 0.01). Bilirubin concentrations were not different. Post partum, carboxyhemoglobin and iron concentrations returned toward normal (1.38% and 50.2 micrograms/dl, respectively). Disparity in the magnitude of increase of heme catabolites produced in equimolar proportion is explained by differences in the kinetics of clearance. The data are most consistent with increased destruction of maternal red cells, even in mild preeclampsia. Potential implications of elevated carboxyhemoglobin on maternal and fetal oxygenation are discussed.

Report of an unusual lymphoma arising from parafollicular B-lymphocytes (PBLs) or so-called "monocytoid" lymphocytes

A distinctive B-cell has been recognized recently in reactive lymph nodes, especially those of toxoplasmic lymphadenitis. Previously designated as "immature sinus histiocytes" or "monocytoid" cells, these B-lymphocytes proliferate in subcapsular and parenchymal sinuses and the parafollicular area of nodes. The authors now report a 55-year-old male who developed a malignant lymphoma composed of cells with light microscopic, immunologic, and ultrastructural characteristics identical with these newly described B-cells. The term parafollicular B-lymphocytes (PBLs) is recommended herein to emphasize their morphologic and immunologic features. An unusual feature of this PBL lymphoma is the numerous benign-appearing hyperplastic follicles surrounded by the neoplastic infiltrate, mimicking the cytologic appearance and distribution of PBLs seen in toxoplasmic lymphadenitis. The function of these recently recognized B-cells is unknown; their anatomic relationship with hyperplastic follicular centers in reactive states and the lymphoma herein described suggests a role in follicular function.

Non-Hodgkin's lymphoma after treatment of Hodgkin's disease: association with Epstein-Barr virus

Non-Hodgkin's lymphoma occurs infrequently as a late complication of obscure cause after treatment of Hodgkin's disease. We investigated the possible role of Epstein-Barr virus in the pathogenesis of such secondary malignancies of B-cell lineage. Two patients, aged 25 and 43 years, developed high-grade non-Hodgkin's lymphomas 12 and 8 years after radiation therapy for Hodgkin's disease. Serologic profiles in these patients showed evidence of acute and past Epstein-Barr virus infections, respectively. Molecular hybridization analysis showed the presence of multiple cellular equivalents of virus genome in tumor specimens from each patient. Our findings suggest that Epstein-Barr virus may play an integral role in the pathogenesis of non-Hodgkin's lymphoma of B-cell lineage that develops after treatment of Hodgkin's disease.

Lymphocyte-depleted Hodgkin's disease. Clinicopathologic review of 25 patients

Clinicopathologic material from 25 patients with lymphocyte-depleted Hodgkin's disease was reviewed. The median age of the patients was 57 years. The patients had no prior diagnosis of Hodgkin's disease and were divided according to pathologic subtype of lymphocyte-depleted Hodgkin's disease: 11 diffuse fibrosis, 10 reticular, and four not otherwise specified. The clinical presentation included B symptoms of fever, weight loss, or night sweats (92 percent), subdiaphragmatic disease (88 percent), frequent marrow involvement (56 percent), and advanced-stage disease (100 percent). Four of 11 patients with diffuse fibrosis had peripheral adenopathy as compared with seven of 10 patients with the reticular subtype (p = 0.3); 10 of 11 patients with diffuse fibrosis had marrow involvement compared with two of nine patients with the reticular subtype (p = 0.006). Among patients who received chemotherapy, median survival was longer in the diffuse fibrosis subtype (nine patients, 39 months) than in the reticular subtype (10 patients, 10 months), p = 0.005. Of the 17 patients who received more than one cycle of combination chemotherapy with mechlorethiamine, vincristine, procarbazine, and prednisone, the median survival was 36 months with 11 (65 percent) complete remissions. In eight patients, disease remains in remission (12 to 127 months) with five patients surviving beyond five years. These results indicate that lymphocyte-depleted Hodgkin's disease has at least two clinicopathologic subtypes and is curable if adequate therapy can be given.

Effects of Mega-COMLA (cyclophosphamide, cytarabine, vincristine, and methotrexate followed by leucovorin and prednisone) plus CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) in the treatment of lymphoid neoplasms with very poor prognosis

Treatment results remain very poor for some clinical and histopathologic subsets of patients with aggressive non-Hodgkin's lymphoma. We treated 21 such patients with a high-dose combination chemotherapy regimen [Mega-COMLA (cyclophosphamide, cytarabine, vincristine, and methotrexate followed by leucovorin and prednisone) + CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone)] in an attempt to improve disease-free survival. Neoplasms were classified using the Lukes-Collins system. Eight patients had T-cell lymphomas (convoluted lymphocytic lymphoma, four patients; T-cell lymphoma/leukemia, one; and peripheral T-cell lymphoma, three), eight had B-cell lymphomas (immunoblastic sarcoma, five patients; small noncleaved follicular center cell, one; and large noncleaved follicular center cell, two), and five had nontypable large noncleaved cell lymphomas. All patients were previously untreated; 18 of 21 patients had clinical stage III or IV disease. Following induction therapy (4-8 weeks' duration), 16 patients (76%) achieved complete remission, while three had partial remission. Two patients died of sepsis during induction therapy. Eleven of 16 complete responders (69%) remain in complete remission after a median follow-up of 35 months. The actuarial 3-year survival rate is 51% for the entire group. Myelosuppression with this regimen was severe and prolonged, with a median duration of neutropenia (less than 500 cells/microliter) of 14 days. Seven patients (33%) developed severe neuropathy following induction treatment. High-dose induction therapy with this regimen resulted in a high complete remission rate with manageable toxicity. Survival results are encouraging when compared retrospectively to our patients with similar poor-prognosis histologies treated with standard combination chemotherapy. However, the value of this intensive therapy, relative to newer ("third-generation") regimens, can only be established by prospective randomized studies.

Malignant histiocytoses developing in patients with B-cell lymphomas. Report of two cases

Two patients with indolent B-cell lymphomas (small B-cell and small cleaved cell) developed a coexistent malignant histiocytosis 3 and 6 years after diagnosis of their lymphomas. In both patients, malignant histiocytosis presented as new onset of fever, weight loss, and rapidly progressive bulky disease super-imposed on a previously stable clinical course without constitutional symptoms. Both patients failed to respond to combination chemotherapy. The terminal aggressive phase of indolent B-cell lymphomas usually represents transformation of the original neoplasm to a large non-cleaved or immunoblastic B-cell histology. Malignant histiocytosis has not previously been reported as a second neoplasm in patients with B-cell lymphomas.

The phenotypic diversity of peripheral T-cell lymphomas: the Southeastern Cancer Study Group experience

Four member institutions of the Southeastern Cancer Study Group (SECSG) investigated 27 cases of malignant lymphoma proved to be of T-cell origin by a frozen section immunoperoxidase technique. The specimens were sent to one central laboratory in Michel's transport medium, where phenotyping studies were performed with a large number of monoclonal antibodies. The phenotypes encountered differed as a group from that reported for lymphoblastic lymphoma, but there was significant diversity within the peripheral T-cell lymphomas. Most tumors were of a mature helper/inducer phenotype (Leu-3+, Leu-2-), but nine of the 27 lymphomas expressed Leu-3 and Leu-2 in other combinations. Half of the lymphomas expressed abnormal T-cell phenotypes in that one or more pan-T-cell markers usually present in nonneoplastic T-cell proliferations were absent. Antibody 3A1 was the pan-T marker that was most frequently lacking in the peripheral T-cell lymphomas. The tumors were also studied for their expression of three markers associated with T-cell activation--HLA-DR, transferrin receptor, and interleukin 2 receptor. The majority of the lymphomas expressed one or more activation markers. However, these three markers appear to be expressed independently. In general, there was no simple correlation between the phenotype of the tumor and the histologic appearance, although neoplasms of morphologically higher grades were somewhat more likely to express T-cell activation markers.

Lymphocyte-depletion Hodgkin's disease. Histopathologic diagnosis of marrow involvement

Lymphocyte-depletion Hodgkin's disease (LDHD) is a rare and often misdiagnosed form of HD. Although marrow involvement is frequent in this disease, most pathologists are not familiar with the marrow lesion of LDHD, since the underlying disease is so unusual. In order to characterize the marrow lesion produced by LDHD, we reviewed biopsies or aspirates from the initial presentation of 22 patients meeting all the clinical and pathologic criteria for LDHD. These included 11 cases of the diffuse fibrosis subtype, eight cases of reticular subtype, and three cases not subclassified. Fifty-four percent of cases, primarily of the diffuse fibrosis subtype, had marrow involvement. Aspirations and biopsies were positive with essentially the same frequency. LDHD produces a characteristic consolidated lesion readily recognized on low-power examination and composed of amorphous, nonbirefringent eosinophilic background material, an inflammatory infiltrate, and Reed-Sternberg (RS) cells. Involvement may be focal and RS cells are generally scarce, requiring examination of multiple sections of well-fixed and stained material. Uninvolved marrow tends to be normocellular and frequently has increased numbers of eosinophils. The original diagnosis of LDHD often may be made from marrow examination alone. Early recognition of marrow involvement is important in facilitating prompt treatment and providing accurate staging without laparotomy.

Monoclonal antibody phenotyping of B-cell non-Hodgkin's lymphomas. The Southeastern Cancer Study Group experience

This report describes the experience of the Southeastern Cancer Study Group (SECSG) with the frozen-section immunoperoxidase phenotyping of 162 cases of B-lineage non-Hodgkin's lymphomas. The authors used a panel of 13 different markers with varying degrees of specificity for B lymphocytes and B-cell neoplasms. All lymphomas were classified according to the International Working Formulation. Several antibodies, including anti-immunoglobulin, B1, Leu 12, and Leu 14 were B-cell-specific markers that were generally pan-reactive. Several other monoclonal antibodies, however, were selectively reactive with subpopulations of B-cell lymphomas. Three "selective-B" antigens (BA1, p24, CALLA) were found on about half of the B-cell lymphomas tested, while another three (HB31, transferrin receptor, C3d receptor) were found on about two-thirds of the lymphomas tested. Leu 1 reacted with 18% of the B-cell lymphomas, particularly the small lymphocytic lymphomas. When the reactivity of the monoclonal antibodies was compared with the histologic classification, two important points became apparent. First, with the large panel of antibodies, there was tremendous phenotypic diversity even among histologically similar tumors. Second, however, not all possible combinations of antibody phenotypes were encountered. That is, clusters of antigenic phenotypes were seen, and these phenotypes correlated to some degree with the histologic diagnosis of the tumor. Small lymphocytic and follicular lymphomas tended to be phenotypically distinct, although there was some overlap. Intermediate- and high-grade lymphomas were phenotypically more diverse. The more common phenotypes of lymphomas encountered could not be reconciled with any simple linear scheme of neoplastic B-cell differentiation.

Plasmacytic differentiation in follicular center cell (FCC) lymphomas

Although follicular centers are the sites of production of plasma cell precursors, plasmacytic differentiation in follicular center cell (FCC) lymphomas is rarely seen, presumably because of a "block" in differentiation of the large noncleaved FCC. The authors reviewed a large number of these cases to determine the frequency of plasmacytic differentiation in FCC lymphomas. In one hundred ninety-eight, consecutive FCC lymphomas with a follicular pattern from a two-year period, 17 (9%) cases were found in which there were large numbers of plasma cells. Immunoperoxidase studies of paraffin-embedded sections (PIP) for cytoplasmic immunoglobulin showed polytypic marking in ten of these and a monotypic plasma cell population in seven. In this latter group, isotypically identical marking of the plasma cell and FCC populations could be demonstrated in three cases with immunoperoxidase (where the FCCs showed cytoplasmic marking) and in one case (of one tested) with surface typing studies. In addition, three patients had serum paraproteins identical to the plasma cell cytoplasmic immunoglobulins. These findings indicate that a small minority of FCC lymphomas contain sufficient plasma cells to be a diagnostic problem, and that in some of these cases, plasma cells are a differentiated component of the FCC lymphomas.

Morphologic and immunologic evidence of composite B- and T-cell lymphomas. A report of three cases developing in follicular center cell lymphomas

Composite lymphoma (CL) may be defined as two lymphomas, differing as to their cell of origin, that occur simultaneously in the same tissue specimen. While CL usually is indicated histopathologically by at least two morphologically distinct lymphomatous proliferations, the proof that these proliferations are separate and distinct neoplasms requires immunologic analysis. Many so-called cases of CL actually represent the well-known phenomenon of lymphoid transformation, in which there is a small cell and a large cell component in the same specimen. Immunologic studies in these cases have shown that the cytologically distinct neoplastic cells represent different stages in the same cell line. While studying a large series of follicular center cell (FCC) lymphomas, the authors recognized three cases in which there was both morphologic and immunologic evidence of a true CL. Following an initial diagnosis of a nodular FCC lymphoma, rebiopsies from 21 to 62 months later showed the coexistence of a nodular FCC (B-cell) component and a diffuse large cell (T-cell) component.

Acute leukemias of childhood: pathologic features

Major advances have been made in the diagnosis and therapy of childhood leukemia over the last two decades (Zuelzer and Flatz, 1960; Miller, 1980; Steinhorn and Myers, 1981; Kobrinsky et al., 1980). Sophisticated phenotypic analysis of these leukemias has partially revealed their complexity; there are at least three to five distinct clinical pathological entities in the childhood leukemia groups. Improved therapy has resulted in marked increases in survival and cures. Less attention has been given to the pathology of childhood leukemia, although the frequency and complexity of tissue examinations have greatly increased. In particular, the pathologic manifestation of relapses, detection of focal leukemia after treatment and the pathology of complications have not been systematically reviewed. Our goal was to look at all of the pathologic manifestations of leukemia and to relate these manifestations to homogeneous patient populations grouped by their type of leukemia. Therefore all of the cytologic, hematologic, histopathologic, ultrastructural and immunologic materials on a consecutive group of leukemic children seen at Vanderbilt from 1970 to 1981 were reviewed; pathologic manifestations of leukemia were then analysed in relationship to diagnostic categories.