Relapse of T-cell all after stem cell transplant presenting as hypertrophic cardiomyopathy: the value of non-invasive diagnostic imaging in detecting cardiac leukemia

We describe a 14-year-old female with acute lymphoblastic leukemia (ALL) with a mediastinal mass at diagnosis who developed hypertrophic cardiomyopathy (HC) after stem cell transplantation (SCT). During refractory relapse after SCT using bone marrow from her HLA-matched sibling, she underwent whole thorax irradiation because of pleural effusion and a recurrent mediastinal mass. After a second SCT using peripheral blood from the same donor, she developed HC suspected to be related to tacrolimus. However, isolated cardiac relapse was finally diagnosed by several non-invasive imaging techniques. Cardiac irradiation resolved her cardiac failure, though she eventually developed progressive and fatal hematological disease.

Myeloid Leukemias and Lung Involvement

Myeloid leukemias are clonal malignancies characterized by the presence of increased numbers of immature myeloid cells in the marrow and peripheral blood. Pulmonary involvement by myeloid leukemia is relatively uncommon and seen mainly in patients with severe disease. The most common form of pulmonary involvement consists of leukemic infiltration along the lymphatics in the peribronchovascular, septal, and pleural interstitial tissue. Less common manifestations include myeloid sarcoma, leukostasis, leukemic cell lysis pneumopathy, and hyperleukocytic reaction. The radiological manifestations of pulmonary leukemic cell infiltration and leukostasis consist mainly of bilateral thickening of the peribronchovascular interstitium and interlobular septa, a pattern that resembles that of interstitial pulmonary edema. The radiological manifestations of leukemic cell lysis pneumopathy and hyperleukocytic reaction consist of symmetric bilateral areas of consolidation. This manuscript reviews the histological and radiological intrathoracic manifestations of myelogenous leukemias.

Granulomatous reactions cause symptoms or clinically imitate treatment resistance in small lymphocytic lymphoma/chronic lymphocytic leukaemia more frequently than in other non-Hodgkin lymphomas

AIMS

The electronic database of the institute of pathology, Medical University of Innsbruck, was reviewed and patient histories studied to analyse systematically the coincidence of granulomatous reactions and lymphomas in a large patient collective, and to find distinct clinicopathological correlations. Five cases of small lymphocytic lymphoma/chronic lymphocytic leukaemia (CLL) associated with granulomatous reactions in lymph nodes and bone marrow were identified, all clinically associated with signs of progressive disease.

METHODS

Cases were acquired by reviewing an electronic database comprising approximately 715,000 patients diagnosed between 1993 and 2003. Histochemical, immunohistochemical, and molecular techniques were used to verify diagnosis and associated infectious diseases. Clinical data were obtained from reviewing the charts.

RESULTS

Of 2044 bone marrow and 411 lymph node non-Hodgkin lymphoma biopsy samples, CLL was most frequently associated with bone marrow (two cases) and lymph node granulomas (three cases). These granulomas were mostly composed of epithelioid cells, with or without giant cells, and in all but one case did not show necrosis. All patients with CLL had clinical symptoms primarily caused by the granulomatous disease: two suffered from acid fast bacilli infections (Mycobacterium tuberculosis and mycobacteria other than tuberculosis) and three presented with clinical manifestations of sarcoidosis (the reason a diagnostic biopsy was performed).

CONCLUSIONS

Granulomatous reactions in patients with CLL might obscure diagnosis and imitate disease progression and Richter's transformation. Careful histological examination, exclusion of infectious agents, and a detailed clinical history are essential for correct diagnosis.

'Specific' cutaneous infiltrate of B-cell chronic lymphocytic leukemia at the site of a florid herpes simplex infection

BACKGROUND

Specific cutaneous infiltrates in patients with leukemia generally carry a grim prognosis. However, non-neoplastic skin diseases may be associated with recruitment of normal and neoplastic leukocytes circulating in the peripheral blood. In those instances, neoplastic cells may be detected in skin lesions without an adverse effect on prognosis.

METHODS

In a patient with B-cell chronic lymphocytic leukemia, a specific infiltrate developed at the site of a florid herpes simplex infection. Clinically, the lesion presented itself as an ulcerated tumor.

RESULTS

Histopathologically, the lesion was characterized by a dense, diffuse infiltrate of small hyperchromatic lymphocytes throughout the entire dermis. Lymphocytes showed an aberrant CD20(+)/CD43(+)/CD5(+) phenotype of neoplastic B cells, and monoclonal rearrangement of immunoglobulin gamma genes could be demonstrated by polymerase chain reaction. Although criteria for leukemia cutis were fulfilled, the patient did well.

CONCLUSIONS

The cutaneous infiltrate of neoplastic cells seemed to be part of a physiologic response to the antigenic stimulus, rather than indicating an exacerbation of leukemia. Ziemer M, Bornkessel A, Hahnfeld S, Weyers W. 'Specific' cutaneous infiltrate of B-cell chronic lymphocytic leukemia at the site of a florid herpes simplex infection.

Leukemic infiltration of the orbit: report of three cases and literature review

Orbital infiltration by acute lymphoblastic leukemia is rare. The authors present 3 patients, 2 with optic nerve involvement and 1 with anterior chamber infiltration, treated by chemotherapy and radiotherapy. Two are in continuous remission at 64 and 59 months and 1 relapsed in the central nervous system 35 months after ocular relapse. Visual deterioration was prevented in two. Early diagnosis and treatment are important for preservation of vision.

Anterior chamber infiltration in a patient with Ph+ acute lymphoblastic leukemia in remission with imatinib

PURPOSE

Anterior chamber involvement is unusual in patients with acute lymphoblastic leukemia (ALL) and has never been described in the setting of Ph+ (Philadelphia chromosome-positive) ALL. Moreover, there have been no reports of this complication as a primary relapse in a patient treated with imatinib.

DESIGN

Interventional case report.

METHODS

A 55-year-old woman with Ph+ ALL in complete remission with imatinib and presenting unilateral anterior uveitis at initial examination was clinically evaluated. Hematologic and ocular studies were performed: blood films, bone marrow smears, and anterior chamber paracentesis with aqueous fluid cytology.

RESULTS

Although there was no evidence of leukemia in the blood or bone marrow samples, aqueous fluid cytology identified Ph+ positive lymphoblastic leukemic cells.

CONCLUSIONS

The patient had developed anterior chamber infiltration without hematological relapse while treated with imatinib. In our opinion, paracentesis should be performed without delay when uveitis develops in ALL, regardless of systemic relapse.

Systemic B-cell chronic lymphocytic leukemia first presenting as a cutaneous infiltrate arising at the site of a herpes simplex scar

Cutaneous infection by Herpes virus (simplex or zoster) is a common non-specific skin manifestation in patients affected by B-cell chronic lymphocytic leukemia (B-CLL) or other malignant lymphomas and is attributed to the patients' immunodeficiency. Persistent or shortly recurrent lesions, however, may represent specific cutaneous infiltrates of systemic B-CLL of several months' duration. The occurrence of these lesions as first manifestation of B-CLL is rare and previously reported only on herpes zoster scars. A case of a 63-year-old male patient with cutaneous B-CLL infiltrate of the right oral commissure at the site of herpes simplex scar as first sign of the disease is herein reported.

[Morphological and immunohistochemical changes in tissues of the lung, myocardium and kidney in experimental West Nile fever]

An experimental infection of mice with West Nile virus (WNV) showed pronounced dystrophic changes in tissues of the kidneys and myocardium as well as expression of WNV antigens in cells of the lungs, kidneys and myocardium, which can denote tropism of WNV to tissues of the lungs, kidneys and myocardium.

Bone marrow angiogenesis and proliferation in B-cell chronic lymphocytic leukemia

OBJECTIVE

To assess angiogenesis and the proliferative activity of bone marrow in patients with chronic lymphocytic leukemia (CLL) in relation to the bone marrow infiltration pattern.

STUDY DESIGN

Bone marrow samples were obtained by trephine biopsy from 46 patients with B-cell CLL (B-CLL). Infiltration pattern was diffuse in 20 patients and nondiffuse--i.e., nodular, interstitial or mixed--in the remaining 26 patients. Ten normal bone marrow samples were used as a control group. Studies were carried out by immunohistochemical staining of paraffin-embedded bone marrow samples. Angiogenesis was assessed in the zones of highest vascular density (hot spots), visualized by the expression of endothelial antigen CD34 and expressed as a number of microvessels per high-powerfield (hpf) (final magnification, 400x). Proliferative activity was estimated by the expression of nuclear protein Ki-67, cyclin A and mean number of nucleolar organizer regions (AgNORs).

RESULTS

Microvessel density was higher in B-CLL marrow than in normal marrow (30.1 and 16.44 per hpf, respectively) and was higher in the diffuse than nondiffuse pattern (33.6 and 27.5 per hpf, respectively). B-CLL bone marrow also showed higher proliferative activity, as assessed by mean number of AgNORs, than did normal marrow (1.52 and 1.25, respectively) and a higher mean percentage of cyclin A-positive cells (7.5 and 6.8, respectively). In contrast, mean Ki-67 expression was similar in B-CLL and the control group. Mean AgNORs number, Ki-67 and cyclin A-positive cell percentage were significantly higher in B-CLL marrow with a diffuse as compared to nondiffuse involvement pattern (AgNORs, 1.75 and 1.35; cyclin A, 9.27% and 3.95%; Ki-67, 34.9% and 23.3%, respectively).

CONCLUSION

Our results indicate enhancement of bone marrow angiogenesis in B-CLL and a relationship between microvessel density and the bone marrow infiltration pattern. The study points also to a possible relationship between the bone marrow infiltration pattern and proliferative activity of bone marrow cells.

Cutaneous leukaemic infiltrations in a patient with previously undiagnosed myelodysplastic syndrome

We report the rare case of a patient with leukaemia cutis first presenting only on the hand and fingers and then subsequently spreading over the trunk and face. The lesions heralded the transformation of a previously undiagnosed myelodysplastic syndrome type RAEB (refractory anaemia with blast excess) into frank myeloid leukaemia. The haematological disease was first detected by the dermatohistopathologist. This case underlines the need to look meticulously for skin changes and perform early skin biopsies in haematological patients, as the skin can reveal the first clinical signs of an otherwise not evident bone marrow disorder. Leukaemia cutis as the initial clinical presentation of a transforming myelodysplastic syndrome type RAEB into acute myeloid leukaemia has been reported only very rarely.

Granulocytic sarcoma presenting with malignant anasarca in a patient with secondary acute myeloid leukemia

Granulocytic sarcomas (GS) are rare extramedullary tumor masses composed of immature cells derived from the hematopoietic myeloid series. GS occur in 3% to 7% of cases of acute myeloid leukemia (AML) and can present before, during, or even after the diagnosis of AML. GS can involve different organs, individually or simultaneously, including the skin, lymph nodes, bone, breast, central nervous system, and lung among others. GS involving peritoneal and pleural fluids is a rare presentation. We present an unusual case of a patient with myelodysplastic syndrome whose disease progressed into a secondary AML and developed GS in the ascitic and pleural effusions as the predominant manifestation of disease progression.

Complete molecular remission of chronic eosinophilic leukemia complicated by CNS disease after targeted therapy with imatinib

Many cases of hypereosinophilia, formerly classified as hypereosinophilic syndrome, can now be characterized as chronic eosinophilic leukemia (CEL) based on the demonstration of characteristic genetic markers indicating clonality of hematopoiesis. Here we report on a 33-year-old male patient with central nervous system manifestations of CEL and an excellent response to low-dose imatinib (Glivec). Molecular analysis demonstrated a constitutive activation of the platelet-derived growth factor receptor-alpha (PDGFR-A) as the mechanism of responsiveness to imatinib.

[The expression of CXCR4 on acute leukemia cells and its implication for extramedullary infiltration]

OBJECTIVE

To study the expression of CXCR4 in acute leukemic cells and its clinical significance.

METHOD

Bone marrow samples from 73 acute leukemia patients and leukemic cell lines were investigated by flow cytometry (FCM), the expression of SDF-1 in human marrow stromal cells and meninges were studied by using reverse transcription polymerase chain reaction (RT-PCR). Adhesion, migration and invasion of U937, NB4 and K562 cells were studied in vitro.

RESULTS

The expression rates of CXCR4 in ALL and AML patients was 65.6% and 17.1%, respectively. And it was 0.2%, 41.0% and 52.0% in K562, U937 and NB4 cells, respectively. The extramedullary infiltration rates were 61.9% and 18.2% for CXCR4 positive and negative groups of ALL, respectively (P < 0.05); while in AML, the number of peripheral white blood cells in CXCR4 positive group was lower than that in CXCR4 negative group (P < 0.05). SDF-1alpha could enhance the adhesion, migration and invasion capacity of leukemic cells in vitro.

CONCLUSION

Overexpression of CXCR4 in AL cells might be the molecular mechanism of extramedullary infiltration in leukemia.

[Pleural involvement in the course of chronic myelomonocytic leukemia and the development of multiple colonic perforation due to leukemic infiltration in the acute leukemia phase]

A 68-year-old man with chronic myelomonocytic leukemia (CMML) was initially treated with hydroxyurea with subsequent stable disease. In the time course, he developed bilateral pleuritis accompanied by leukocytosis and spiking fever. Cytologic analysis of the pleural effusion revealed abundant mature granulocytes and monocytes. He was treated with intravenous or oral etoposide with consequent resolution of the pleuritis, indicating the pleural involvement of CMML. Three months later, he developed hepatomegaly and became febrile. One month thereafter, the CMML transformed to acute myeloid leukemia, and the patient developed massive bloody stools associated with epigastric pain and leukocytosis. A gastrofiberscopic examination showed multiple bleeding gastric ulcers. The bleeding ulcers were treated with the clipping procedure; however, the bloody stools continued. Although intravenous etoposide was effective for the leukocytosis and hepatomegaly, the treatment did not improve the bloody stools. The patient finally died of panperitonitis. The autopsy showed multiple ulcers of the transverse colon, some of which were perforated. Microscopically, the ulcerated areas were densely infiltrated with leukemic cells predominantly consisting of immature monocytes and granulocytes. This patient may be the first reported case of CMML complicated by colonic perforation due to leukemic infiltration.

Leptomeningeal precursor B-cell lymphoblastic lymphoma in a child with minimal bone marrow involvement

The authors report an unusual presentation of a leptomeningeal lymphoblastic lymphoma in a 6-year-old boy with headache and papilledema as the only initial manifestations. The diagnosis was confirmed by the presence of precursor B-cell lymphoblasts in the cerebrospinal fluid, with no cerebral mass and with only 9% phenotypically identical blasts in the bone marrow. This patient was treated on a high-risk ALL protocol with intensive systemic/intrathecal chemotherapy plus cranial irradiation, and he remained in complete remission 6 months after his initial diagnosis.

Acute myeloid leukemia presenting as bilateral proptosis from diffuse extraocular muscle infiltration

PURPOSE

To report a case of acute myeloid leukemia with bilateral proptosis as the sole presenting sign.

DESIGN

Observational case report.

METHODS

A patient with bilateral proptosis was seen in consultation by pediatric ophthalmology.

RESULTS

Complete blood count, computerized tomography, and bone marrow biopsy confirmed the diagnosis of acute myeloid leukemia, with the proptosis due to diffuse infiltration of all extraocular muscles.

CONCLUSION

In a child with the sudden onset of proptosis without any other systemic findings, the diagnosis of acute leukemia must be considered.

Disseminated linear calcinosis cutis associated with the Koebner phenomenon in an infant with congenital acute monocytic leukaemia

We present a unique case of an infant with acute monocytic leukaemia who presented at birth with multiple rubbery, erythematous to violaceous subcutaneous nodules secondary to leukaemia cutis. As these infiltrates regressed with chemotherapy, numerous white to yellow linear confluent papules appeared in a scratch-like pattern. These lesions were widely disseminated but were concentrated across her face, trunk and extremities with relative sparing of the napkin area and back. We propose that these lesions represent a form of dystrophic calcinosis cutis that occurred secondary to koebnerization in an infant with congenital leukaemia cutis.

Insuffisance hépatique aiguë sévère et syndrome d’activation macrophagique : cause ou conséquence ?

Haemophagocytic syndrome corresponds to an unconnected macrophagic activity with haemophagocytosis. We report the case of a haemophagocytic syndrome in a 49-year-old woman with initially a severe acute hepatic failure. This syndrome is probably underestimated in ICU patients. Haemophagocytic syndrome should be suspected in patients with fever and jaundice without infection.

Aleukaemic leukaemia cutis: case report and review of the literature

'Aleukaemic leukaemia cutis' or acute leukaemia confined to the skin is extremely rare, although skin involvement with underlying leukaemia is well recognized, and is associated with a poor prognosis. We report a case of isolated acute myeloid leukaemia (AML) in the skin. A literature review shows this to be commonly misdiagnosed. Its recognition is important, because early diagnosis should lead to more appropriate chemotherapy, and a better prognosis. These patients probably require therapy directed specifically to the skin, as well as to other extramedullary sites, such as the central nervous system, to prevent early relapse.

Ocular Involvement in Leukemia – A Study of 288 Cases

Two hundred and eighty-eight newly diagnosed cases of leukemia (164 males and 124 females, 167 adults and 121 children, 245 acute and 43 chronic, 151 myeloid and 137 lymphoid), aged between 6 weeks and 78 years, were examined for eye changes in the oncology wards within 2 days of diagnosis before starting chemotherapy. Ocular lesions were present in 102 patients (35.4%)--retinal vascular changes in 91 (31.6%); infiltration of ocular tissues in 5 (1.7%), and neuro-ophthalmic signs in 6 (2.1%) cases. Some of the patients had more than one ocular lesion in one or both eyes. The eye changes were seen more often in adults (49.1%) than in children (16.5%), and in myeloid leukemia (41.0%) than in lymphoid leukemia (29.2%). Eye symptoms were present in 29 patients (10%) at initial diagnosis. Since ocular lesions were detected in many asymptomatic leukemia patients, eye examination should be included as a part of routine evaluation at initial diagnosis in these patients.

Cerebral involvement as the initial manifestation of chronic lymphocytic leukaemia

A 53-year-old man presented with focal jacksonian seizures that were due to cerebral tumour manifestations. Stereotactic biopsy revealed infiltration by lymphocytes compatible with the diagnosis of chronic lymphocytic leukaemia (CLL). Simultaneously, Binet stage II CLL with bone marrow infiltration was diagnosed. Cranial radiotherapy with 36 Gy was performed. One year after diagnosis, the patient is in stable disease. Cerebral involvement is rare but may occur in early CLL. Cranial radiotherapy may lead to lasting remission. In case of spinal fluid involvement intrathecal chemotherapy is recommended.

Coexistence of chronic lymphocytic leukemia and essential thrombocythemia

The association of chronic lymphocytic leukemia (CLL) with essential thrombocythemia (ET) is an extremely rare event and until now 3 patients with such coexistence have been reported in the literature. We report a 77-year-old white woman in whom these two disorders were diagnosed concomitantly on the basis of peripheral blood count and cytology, bone marrow cytology and histology, immunophenotyping, as well as exclusion criteria. The diagnosis of ET was also supported by spontaneous in-vitro erythroid colony growth and by evaluation of thrombopoietin (TPO) serum level. Interphase FISH analysis allowed to detect 13q14.3 deletion in 98% of lymphocytes nuclei. In contrast this aberration was not observed in the megakaryocytes. The results of PCR analysis of IgG gene rearrangement showed distinct bands characteristic for monoclonal lymphoid population in bone marrow, peripheral blood and inguinal lymph node. The patient was started on hydroxyurea 1 g/day and normalization of the platelet count was achieved. Possible etiopathogenic relationships between both disorders and differential diagnosis of ET and reactive thrombocytosis (RT) are discussed.

Chronic lymphocytic leukemia and multiple myeloma in the same patient: case report

We hereby report the occurrence of a non-secreting multiple myeloma (MM) during the course of chronic lymphocytic leukemia (CLL). A 73-year-old patient developed a non-secreting MM 7 years after the diagnosis of CD5 (+) B cell CLL. He received intermittent chlorambucil and prednisolone therapy. The occurrence of tumors in the frontal bone led to resection of the tissue and histopathologic examination revealed neoplastic plasma cell islands within the CLL infiltration. There was no immunoglobulin or light chain accumulation in the serum. Clonal relationship between these diseases has been shown by comparing the isotypes and idiotype of both the heavy and light chains. In our case, the MM was of non-secreting type and thus we could not establish any relation between the 2 disorders. Such a case has not been reported until now in the literature. CLL and MM in the same patient is a rare occurence and investigation of the transformation event at the molecular level will contribute to our understanding of B-cell ontogenesis.

Extensive neoplastic cardiac infiltration in a patient with acute myelogenous leukemia: role of echocardiography

We present the case of a 34-year-old man with a history of relapsed acute myelogenous leukemia with extensive metastatic infiltration of the endomyocardium. Transesophageal echocardiography revealed masses within all the cardiac chambers and associated vascular structures. Biopsy of the superior vena cava mass had the histological features of a granulocytic sarcoma (GS, chloroma). Massive involvement of the heart with GS is very rare, and only a few reports have been published in the literature.

Prominent intrasinusoidal infiltration of the bone marrow by mantle cell lymphoma

Intrasinusoidal infiltration of bone marrow (BM) may accompany several malignant lymphoproliferative disorders. In small B-cell lymphomas, this pattern is considered specific for splenic marginal zone lymphoma (SMZL) when exclusive or prominent, although it may occur in other subtypes of non-Hodgkin's lymphomas (NHLs) as a minor feature. Here we report 2 cases of mantle cell lymphoma (MCL) with a prominent intrasinusoidal BM infiltration pattern. Both patients presented with massive splenomegaly and peripheral blood involvement characterized by markedly atypical lymphocytes, but no lymphadenopathy. The cytological features and the phenotype of the lymphoma cells were diagnostic of MCL. The malignant B cells showed coexpression of B-cell markers (CD20+ and CD79a+), CD5 antigen, and cyclin D1 by immunohistochemistry. We discuss the specificity of an intrasinusoidal growth pattern in the bone marrow, emphasizing the importance of using a broader immunohistochemical panel in the differential diagnosis of intrasinusoidal BM infiltration by NHL.

A diagnosis of chronic lymphocytic leukemia prompted by cutaneous lymphocytic infiltrates present in mohs micrographic surgery frozen sections

BACKGROUND

Chronic lymphocytic leukemia (CLL) is the most common form of leukemia in the United States. Patients with CLL are at an increased risk for the development of second malignant neoplasms, the most common of which is cuta-neous squamous cell carcinoma (SCC). Cutaneous infiltrates of CLL have been reported in association with primary cutaneous neoplasms, including SCC, basal cell carcinoma, and actinic keratosis. The finding of a dense lymphocytic infiltrate surrounding a cutaneous neoplasm should prompt consideration of possible underlying CLL.

OBJECTIVE

To review the relationship of CLL to cutaneous SCC and to raise awareness of the possible coexistence of these two neoplasms.

METHODS

The case report describes a patient with a SCC of the left cheek treated with Mohs micrographic surgery. A dense lymphocytic infiltrate was noted on the frozen sections, and a complete blood count was obtained.

RESULTS

A lymphocytosis was detected, leading to the diagnosis of CLL, stage 0.

CONCLUSION

Patients with CLL are at an increased risk for the development of cutaneous neoplasms. An infiltrate of leukemic cells in documented CLL patients can be associated with cutaneous neoplasms such as SCC. We present a patient with no known hematologic malignancy who demonstrated a dense lymphocytic infiltrate on Mohs sections. The diagnosis of CLL was considered based on the appearance of this infiltrate. Subsequently, a new case of CLL was confirmed with appropriate testing. The finding of a dense subcutaneous infiltrate of lymphocytes on Mohs frozen sections should raise the possibility of CLL and lead to appropriate screening tests.

Chronic lymphocytic leukemia with prostate infiltration mediated by specific clonal membrane-bound IgM

Chronic lymphocytic leukemia (CLL) is characterized by an accumulation of monoclonal B lymphocytes in the hematopoietic organs. Rarely, CLL cells accumulate in a single atypical site. The mechanism underlying this unusual distribution of CLL cells has not been studied previously. We obtained peripheral blood from five patients having early stage CLL with heavy prostate infiltration. These patients' circulating CLL cells bound strongly in vitro to cultured prostate cell lines PC3, LNCaP, and DU145 and to short-term cultures of fresh prostate cells but not to colon, breast, or bladder cells. CLL cells from patients without prostate infiltration did not bind in vitro to any cell line. Peripheral blood CLL cells from one patient with CLL with heavy prostate infiltration were fused with a mouse-human heteromyeloma line to make hybridomas expressing the same monoclonal IgM as the patient's CLL cells. The hybridoma cells bound specifically to prostate cells. IgM secreted by the hybridoma blocked binding of the patient's CLL cells to prostate cells. Flow cytometry and immunohistochemistry demonstrated that the secreted IgM bound specifically to prostate cells. These results indicate that CLL with atypical prostate infiltration can be mediated by specific surface-bound IgM against an antigen expressed specifically by prostate cells and suggest that a similar mechanism might also apply to cases of CLL with atypical infiltration into other organs.

Acute myeloid leukemia mimicking primary testicular neoplasm. Presentation of a case with review of literature

We describe a new unique case of acute myeloid leukemia (AML) in a 21-yr-old male presenting with abdominal pain, bilateral testicular masses and gynecomastia. Further work-up with computed tomography of the chest, abdomen and pelvis revealed massive retroperitoneal, peripancreatic and mediastinal lymphadenopathy, suggesting primary testicular neoplasm. The patient was subjected to right orchiectomy that showed infiltration of testicular tissue with malignant cells, originally misinterpreted as undifferentiated carcinoma. Immunohistochemistry studies, however, showed these cells to be strongly positive for myeloperoxidase and CD45, indicating a myeloid cell origin. Bone marrow (BM) aspirate and biopsy demonstrated replacement of marrow with immature myeloid cells. Both the morphology and immunophenotype of the blast cells were consistent with AML type M4 (acute myelo-monocytic leukemia), using French-American-British (FAB) classification. The patient received standard induction chemotherapy with cytosine arabinoside (ARA-C) and daunorubicin followed with two cycles of consolidation therapy with high dose ARA-C, which resulted in remission of BM disease and resolution of lymphadenopathy and left testicular masses. After the second cycle of consolidation therapy, the patient developed sepsis that was complicated by refractory disseminated intravascular coagulopathy. He expired with a clinical picture of multiple organ failure. The unique features of this case are presented and the related literature is reviewed.

The effects of the levonorgestrel intrauterine system (Mirena coil) on endometrial morphology

AIMS

The Mirena coil is a levonorgestrel releasing intrauterine device that is in widespread use. This study aims to document the endometrial morphology associated with this device.

METHODS

Endometrial specimens from 75 women with the Mirena coil were reviewed and the histological features detailed.

RESULTS

Morphological features found in most of the endometria were decidualisation of stroma (72 of 75 cases), atrophy of endometrial glands (65 of 75 cases), a surface papillary pattern (38 of 75 cases), and a stromal inflammatory cell infiltrate (59 of 75 cases). Additional common histological features were the presence of foci of stromal myxoid change (29 of 75 cases) and stromal haemosiderin pigment (24 of 75 cases). Reactive atypia of surface glands, glandular metaplastic changes, stromal necrosis, and stromal calcifications were found in small numbers of cases.

CONCLUSION

The endometrial features are characteristic and relatively constant and are in keeping with the effects of both a progestogenic compound and a mechanical device. Pathologists should be aware of these histological features because the Mirena coil is in widespread use.

Sudden death due to lymphomatous infiltration of the cardiac conduction system

We present the case of a 62-year-old white female with a history of previously treated angioimmunoblastic T-cell lymphoma, who died suddenly 1 day after presentation for presumed tumor recurrence. Postmortem gross examination revealed a 4-cm cardiac mass that was adherent to the free wall of the right atrium. Histologic examination showed extensive infiltration of the cardiac conduction system by lymphoma, which likely lead to fatal arrhythmia. Histological examination revealed systemic dissemination by an Epstein-Barr virus (EBV)-positive large B-cell lymphoma. Careful examination of the cardiac conduction system on serial sections was crucial in documenting the cause of death due to lymphomatous infiltration. As in this patient, lymphomatous infiltration of the heart may produce sudden cardiac death without obvious premortem signs of cardiac compromise. This case illustrates the utility of examination of the cardiac conduction system in necroscopy studies of sudden death.

Lymphocytic infiltrates and subclinical epithelial tumor extension in patients with chronic leukemia and solid-organ transplantation

BACKGROUND

Dense infiltrates in association with squamous cell carcinoma (SCC) or basal cell carcinoma (BCC) in patients with underlying chronic lymphocytic leukemia (CLL) may complicate pathologic interpretation of histologic margins.

OBJECTIVE

The study was conducted to determine the frequency of identifying dense inflammatory infiltrates in frozen histologic sections during Mohs operation for BCC or SCC in patients with CLL and organ-transplant recipients, to characterize the infiltrate (reactive versus leukemic) in CLL, and to estimate the subclinical tumor extension in patients with CLL, transplant recipients, and control subjects undergoing Mohs procedure.

METHODS

Frozen sections of head and neck BCC and SCC obtained during Mohs procedures in patients with CLL, organ transplant recipients, and a control group were reviewed retrospectively. Biopsy specimens of CLL with dense infiltrates were assessed with immunohistochemical stains. Subclinical tumor extension (postoperative defect size minus preoperative tumor size) was evaluated in each group.

RESULTS

Dense infiltrates were found in tumors of 20 of 55 patients with CLL (36%), 1 of 8 transplant recipients (13%), and 1 of 105 controls (1%). In patients with CLL, 75% of the dense infiltrates were B-cell leukemic. Compared with controls, the mean subclinical tumor extension was larger in patients with CLL (P=0.029) and in transplant recipients (P=0.55).

CONCLUSION

Dense leukemic infiltrates associated with BCC or SCC in CLL may complicate pathologic interpretation of Mohs surgical histologic margins and may be associated with larger postoperative defects relative to preoperative clinical tumor appearance. In patients with CLL, as in transplant recipients, SCC seems more likely to develop than BCC.

Bilateral optic nerve infiltration in central nervous system leukemia

PURPOSE

To report the case of a 58-year-old man with sequential bilateral retrolaminar leukemic infiltration of the optic nerves who presented with normal-appearing optic nerves and no optic nerve enhancement.

DESIGN

Interventional case report.

METHODS

A 58-year-old man with chronic myelogenous leukemia (CML) developed progressive vision loss to no light perception in both eyes over four days. The patient received 14 doses of external beam irradiation and 10 cycles of intrathecal cytarabine. Despite treatment, he developed optic nerve pallor, and visual acuity remained no light perception in both eyes.

CONCLUSIONS

In a patient with leukemia, leukemic optic nerve infiltration may occur even with normal-appearing optic nerves and a normal magnetic resonance image. It is important to maintain a high clinical suspicion for optic nerve infiltration so that prompt local irradiation may be initiated.

Leukemic dissemination within a glioblastoma in a patient with chronic lymphoid leukemia

Metastasis from an extracranial tumor to a primary central nervous system tumor is a rare event, and most reported cases concern metastases to meningiomas. The authors describe the first case of leukemic cell dissemination within a glioblastoma. The patient likely presented a genetic predisposition to multiple neoplasms, and the unusual localization of leukemic cells might be partly related to the characteristic microvascular proliferation in glioblastoma.

Intraocular infiltration of adult T-cell leukemia

PURPOSE

To report a case of adult T-cell leukemia (ATL) with unilateral dense vitreous opacities that benefited from vitrectomy.

DESIGN

Interventional case report.

METHODS

Diagnostic vitrectomy was performed on a 59-year-old man with ATL who had vitreous opacity in the right eye.

RESULTS

White infiltration of the retina was noted after vitrectomy. Cytologic examination of the vitreous specimen obtained during surgery revealed infiltration of ATL cells into the vitreous and retina. After vitrectomy and additional chemotherapy, visual acuity improved in the right eye from 20/100 to 25/20.

CONCLUSION

Infiltration of the vitreous and retina by ATL is rare. Diagnostic vitrectomy is effective for treatment and visual improvement.

Unexplained acute renal failure in a toddler: a rare complication of Epstein-Barr virus

A previously healthy toddler developed severe acute renal failure with nephromegaly and peripheral atypical lymphocytosis. Profound interstitial nephritis with acute tubular necrosis was diagnosed by renal biopsy, and both the clinical picture and serological evaluation suggested Epstein-Barr virus (EBV) as the etiological agent. The previous reports of EBV-induced renal failure and the clinical and pathological presentations of interstitial nephritis in children are reviewed.