Cutaneous xanthomatous tumours as an expression of chronic myelomonocytic leukaemia?

Nonspecific cutaneous xanthomas have been reported in a variety of lymphocytic neoplastic processes, but to date only three cases of xanthomatous lesions associated with monocytic leukaemias have been described. We now report a patient with a chronic myelomonocytic leukaemia (CMML) associated with these lesions. The clinical and immunohistochemical features do not correspond to any entity previously described and suggest that xanthomas is are a cutaneous expression of the CMML.

[Homogeneous clinical behavior of a group of cutaneous B-cell lymphomas]

PURPOSE

To assess the non-cutaneous involvement in primary B-cell non-Hodgkin's lymphoma (NHL) of the skin.

PATIENTS AND METHODS

Data from 45 patients with B-cell NHL of the skin were retrospectively analysed. The patients were diagnosed on histologic and immunocytochemical grounds between June 1977 and July 1993, and 14 cases were selected for their exclusively cutaneous initial involvement. Initial treatment, response to therapy, disease-free survival characteristics of relapse and therapeutic sequence were evaluated in every case.

RESULTS

Cutaneous involvement presented as nodules or patches, on a single location, in 12 cases, or disseminated, in 2 others. No prognostic factor could be identified, and complete remission was attained in all cases. Cutaneous relapse was seen in 7 patients after 4 to 108 months since diagnosis. Extracutaneous dissemination was not seen in any case, and 13 patients are alive and disease-free. A 90 year-old woman died of toxic complications.

CONCLUSIONS

The clinical facts reported here confirm the not too aggressive behaviour of certain B-cell cutaneous NHL, probably related with their origin on the skin itself.

[Expression of latent membrane protein (LMP) in large-cell anaplastic lymphomas]

PURPOSE

The presence of Epstein-Barr virus (EBV)-encoded latent membrane protein (LMP) was investigated in 40 cases of lymphoproliferative diseases which include Hodgkin's disease (HD), anaplastic large cell lymphoma (ALCL) and non-Hodgkin's lymphoma (NHL) of B and T-cell nature.

MATERIAL AND METHODS

All cases were immunophenotyped in paraffin-embedded lymph node tissues, with a complete panel of monoclonal antibodies against B-cells, T-cells, histiocytes, activation and proliferation markers and classified as: 24 anaplastic large cell lymphoma (ALCL, 8 classical type and 16 ALCL-HD related), 10 lymphocyte predominant HD (LP, 5 classical type and 5 with ALCL areas), 4 NHL (two T-Cell type and 2 T-cell rich B-cell NHL). Immunohistochemistry techniques were performed ABC-complex and phosphatase alkaline anti-phosphatase alkaline (APAAP).

RESULTS

LMP was detected in 35% (14/40) of total cases. In LP group one third of cases were LMP+. In ALCL-HD related cases 44% were LMP+ versus 13% in ALCL group. All LMP cases were CD30+ except one NHL-T and a T-cell rich B-cell NHL. The predominant immunophenotype was LMP+/CD20+ (57%) versus LMP+/CD20-. Most cases were of B-cell (36%) lineage. Null ALCL cases were LMP-.

CONCLUSIONS

LMP, the most oncogenic EBV protein could play a pathogenic role in lymphoproliferative processes. It is not exclusive of HD and appears in other NHL preferentially of B-cell nature, above all in ALCL cases relating the two neoplasias HD and ALCL, both CD30 positive.

Infrequent expression of protein p53 in epidermotropic variants of cutaneous T-cell lymphoma

Although diverse types of lymphomas have been examined for immunohistochemical detection of p53 protein, little information is available with regard to p53 protein expression in CTCL. We analyzed cutaneous biopsy specimens of 22 patients with the diagnoses of mycosis fungoides or Sézary syndrome with polyclonal rabbit anti-p53 antiserum CM-1. Staining of neoplastic cells was observed only in two patients with advanced disease. Overexpression of p53 protein does not seem to be a major feature of either mycosis fungoides or Sézary syndrome.

Evaluation of clonal immunoglobulin heavy chain rearrangements in Hodgkin's disease using the polymerase chain reaction (PCR)

We have correlated histologic type of Hodgkin's disease, degree of Hodgkin and Reed-Sternberg cell infiltration, percentage of Hodgkin and Reed-Sternberg cell positivity for latent membrane protein, immunophenotype of Hodgkin and Reed-Sternberg cells, and immunoglobulin heavy chain (IgH) gene rearrangements detected by polymerase chain reaction (PCR) in 56 unselected Hodgkin's disease cases. Two protocols were used for amplification of IgH gene using Fr2 or Fr3 V-region primers, in conjunction with nested primers directed to the JH region. PCR products were run on polyacrylamide gels. Immunohistochemical studies were performed on paraffin sections using monoclonal antibodies for CD20 and latent membrane protein, and polyclonal antibody to CD3. Using both primer combinations we detected a definitive clonal band in 23.2% of the Hodgkin's disease cases. Clonal IgH rearrangements were detected in 23.6% of nodular sclerosis type and in 28.5% of mixed cellularity type. Using a highly sensitive method such as PCR, more than 20% of unselected cases of Hodgkin's disease were found to contain B-cell clonal proliferations, but there was no correlation between histological and immunological parameters and molecular analysis results.

Gastric B-cell mucosa-associated lymphoid tissue (MALT) lymphoma. Clinicopathological study and evaluation of the prognostic factors in 143 patients

BACKGROUND

Gastric MALT lymphoma can be histologically classified into two groups, low-grade (LG) and high-grade (HG); however, their natural history is poorly understood. We have studied a large retrospective series aiming to confirm whether the histological groups confer different clinical features and behavior and to analyze the prognostic factors in these patients.

PATIENTS AND METHODS

A series of 143 gastric B-cell MALT lymphomas is reported. Eighty-four were low-grade lymphomas (LG) and 59 were high-grade lymphomas (HG). Median follow-up was 36 months. The clinical and analytical parameters of the 84 LG patients were compared with those of the 59 HG patients. In the patients who had been operated on, the pathological features (macroscopical patterns, tumor size, involvement of resection margins, degree of parietal invasion and involvement of abdominal lymph nodes and adjacent viscera) of the LG patients were compared with those of the HG patients. The sites of relapses were studied. In the 132 treated and followed-up patients the influence of the treatment and that of clinical, analytical and pathological features on survival were investigated with the Kaplan and Meier and log-rank tests. To identify the factors with independent influence on survival, a Cox model was fitted for the whole series and separately for 53 HG patients.

RESULTS

HG group differed from the LG group by a significantly higher frequency of weight loss at presentation, palpable abdominal mass, hepatomegaly, peripheral lymphadenopathy, elevated serum LDH, higher incidence of stage III-IV and tumor/mass patterns in the endoscopy and in the gastrectomy specimen. The tumor was significantly larger in the HG group than in the LG and the deeper invasion of the gastric wall, the higher frequency of infiltration of the abdominal lymph nodes and the visceral extension were also significant in the HG group. Complete remission (CR) was achieved in 91% of the patients of the LG group, but was significantly lower, 70%, in the HG group. Relapses occurred in the stomach and also in non-MALT sites. In 132 treated and followed-up patients, elevated serum LDH, absence of CR, HG group and stage III-IV were associated with a worse survival. In the Cox multivariate model, stage was the only variable influencing survival, although stage was related to the histological grade. In the HG group, stage was also an independent significant risk factor, whereas treatment with surgery, chemotherapy or both was not. In the 103 patients treated with surgery, a worse survival was associated with the involvement of the resection borders, depth of the infiltration of the gastric wall, dissemination to distant abdominal nodes and adjacent organs, but not with the addition of chemotherapy.

CONCLUSIONS

Histological classification into LG and HG separates distinctive groups of gastric MALT lymphoma that show striking clinical and prognostic differences. Besides histological grade, stage is the most important prognostic feature.

Waldeyer ring lymphomas. A clinicopathological study of 79 cases

Waldeyer ring lymphomas belong to a category of tumours which has not yet been fully defined. Their relation to mucosa-associated lymphoid tissue (MALT) and other extranodal lymphomas remains largely unknown. We performed a clinicopathological retrospective study of 79 patients, and compared them with a series of MALT and nodal lymphomas. Tumours from the nasopharynx and palatine tonsil showed similar histological profiles, with a predominance of large B-cells. Centroblastic lymphomas constituted the largest group (n = 45), followed by those of centrocytic type (9) with smaller groups of centroblastic-centrocytic (5) and Hodgkin's lymphomas (2). Three monocytoid B-cell lymphomas were identified. Only one case could be classified as MALT lymphoma. The frequency of bcl-2 expression in large B-cell tumours of Waldeyer's ring has an intermediate range between large B-cell lymphomas occurring in mucosal and nodal locations. Epitheliotropism was present in all low-grade cases, and was therefore not a useful marker in the identification of potential MALT lymphomas in contrast with other mucosal sites. Comparative survival studies showed significant overall differences between Waldeyer ring lymphomas, MALT and nodal cases. These disappeared after taking stage and histological grade into account. We conclude that Waldeyer ring lymphomas show distinctive features, mainly in terms of histological distribution and immunophenotype. The key factor determining their behaviour could be their different spreading capability. These findings suggest that extranodal lymphomas are heterogeneous, and indicate the need for additional efforts to clarify this.

Detection of Epstein-Barr genome in the lymph nodes of Hodgkin's disease

We have used the enzymatic in situ hybridization method to investigate the presence of Epstein-Barr virus (EBV) genome in lymph node tissues from patients with Hodgkin's disease. Also, 11 patients with persistent human immuno-deficiency virus-associated generalized lymphadenopathy as well as seven autopsy cases with no Hodgkin's disease, formed part of these studies. EBV DNA-positive reaction was demonstrated in Reed-Sternberg cells and variants in seven of 16 cases and in the small accompanying lymphocyte cell population in 14 of the 16 cases. It was also found in eight of the 11 cases with persistent generalized lymphadenopathy but in none of the lymph nodes from negative selective autopsy cases. Our results indicate that the colorimetric in situ hybridization technique is useful in EBV nucleic acid detection and cell-type localization in Hodgkin's disease. Additionally, the detection of EBV genome, not only in the diagnostic cells but in the small lymphocyte cell components, could provide new insights into the potential role of this agent in the pathogenesis of Hodgkin's disease.

Metastatic carcinoma of the prostate presenting as a superior vena cava syndrome

A 75-year-old patient presented with a superior vena cava syndrome (SVCS) lasting 3 years. A prostatic carcinoma was found and a supraclavicular lymph node biopsy specimen disclosed metastasis of the prostatic carcinoma. Antiandrogen and luteinizing hormone-releasing hormone analogue therapy produced a marked improvement. Prostatic carcinoma, although a very rare cause, must be considered in the diagnosis of cases of SVCS with a protracted course, since it is a treatable disease.

Peripheral T-cell lymphoma: a clinicopathological study of 41 cases and evaluation of the prognostic significance of the updated Kiel classification

A total of 41 non-cutaneous peripheral T-cell lymphomas were classified following the updated Kiel classification. Of these, 20 cases belonged to the low-grade group (T-cell chronic lymphocytic leukaemia, 3; lymphoepithelioid, 5; angioimmunoblastic, 4; pleomorphic small cell, 8) and 21 to the high grade group (pleomorphic medium and large cell, 11; immunoblastic, 3; large-cell anaplastic Ki-1 positive, 7). Seventy per cent showed a CD4+/CD8-phenotype, 39% a defective phenotype and 88% an activation phenotype. Eighty per cent had B-symptoms, 63% hepatomegaly, 48% splenomegaly and 26% had involvement of more than three lymphoid areas. Bone marrow was infiltrated in 34%, central nervous system in 4%, lung in 12% and skin in 14.6%. Seventeen per cent presented with extranodal disease and 82.8% had stage III/IV disease. Hypergammaglobulinaemia was found in 29%, hypercalcaemia in 7%, raised LDH serum levels in 58% and HTLV-I antibodies in only one case. Of the 37 treated patients 18 (48%) achieved a complete remission, but 33% relapsed. Mortality was 59% and actuarial overall survival at 38 months was 0.32. In the comparison of the clinical, analytical and immunophenotypic variables and outcome between low and high grade groups, only the average of bone marrow infiltration in the low grade and stage I-II, presence of defective phenotypes and higher Ki-67 positivity in the high grade group were significantly different.(ABSTRACT TRUNCATED AT 250 WORDS)

In situ demonstration of Epstein-Barr virus in intravenous drug abusers with generalized lymphadenopathy

We have studied by the in situ hybridization method the presence of Epstein-Barr virus (EBV) DNA genome in lymph node tissues from 11 patients with persistent generalized lymphadenopathy. Using a biotinylated EBV DNA probe, we demonstrated EBV nucleic acid in scattered germinal centre cells in eight of the 11 cases. Our results suggest that EBV is not a determinant factor in the pathogenesis of this lymphadenopathy, but support its possible implication in B cell malignant transformation in cases of AIDS-associated lymphoma.

Pleural effusion as first sign of extramedullary plasmacytoma

A patient with mediastinal EP with extension to pleural spaces and subsequent pleural effusion is described. The finding of many plasma cells in pleural fluid led to diagnosis. Similar histologic findings such as multiple myeloma and immunoblastic lymphoma were ruled out by clinical approach and immunochemistry, respectively. This pleural effusion represents the first case described caused by EP.

Human germinal centre B cells inhibit mitogen-induced proliferation of mantle zone B cells

Lymphoid follicles are the main B-cell areas in peripheral lymphoid tissues. These structures commonly consist of germinal centre (GC) and mantle zone (MZ) regions. In the present work, human tonsillar B cells belonging to these two compartments were purified by a combination of density centrifugation and separation techniques involving the recognition by monoclonal antibodies of specific surface molecules followed by panning and magnetic bead selection. These purified populations were identified as GC and MZ cells by three different criteria: (1) GC cells showed the phenotype IgD- CD20+bright CD38+ CD44- and peanut agglutinin (PNA)+, and MZ cells were IgD+ CD20+dim CD38- CD44+ and PNA-; (2) morphologically, MZ cells appeared as small resting lymphocytes whereas GC cells consisted of large blastic cells of the germinal centre; (3) functionally, most GC, but not MZ, cells underwent apoptosis early in culture. The isolation of GC and MZ cells allowed the study of their proliferative response. As a result of these studies, GC cells were demonstrated to inhibit the proliferation of MZ cells in response to B-cell mitogens (Staphylococcus aureus Cowan I and anti-mu plus BCGF) in a concentration-dependent way; 50% inhibition was reached at a GC/MZ cell ratio of 1/2. This effect did not require GC-cell DNA synthesis since similar results were obtained with irradiated GC cells. Neither was it due to a non-specific toxic effect since GC cells did not alter the proliferative response of autologous T cells to mitogens (phytohaemagglutin and anti-CD3). The inhibition required cellular contact between GC and MZ cells, and was not restricted by histocompatibility barriers. These data suggest the possible existence of a new regulatory pathway within peripheral B-cell areas.

[Pure red-cell aplasia associated with chronic myeloproliferative syndromes]

Pure red cell aplasia is manifested by unregenerative anemia with intense erythroid hypoplasia in the bone marrow and absolute reticulocytopenia. Its association with chronic myeloproliferative syndrome (CMS) is infrequent. The appearance of both processes may or may not be simultaneous and accidental association cannot be ruled out. Two cases of pure red cell aplasia were studied; one associated to Philadelphia positive chronic chromosome myeloid leukemia and the other associated to atypical CMS. In the first case no response was obtained with prednisone alone or associated to cyclophosphamide. In the second patient treatment with danazol was not efficient, however, corticotherapy produced a positive and maintained response. Treatment of pure red cell aplasia associated to CMS must be the same as that employed when this disease is presented as isolated or associated to other processes.

[The treatment of large-cell non-Hodgkin's lymphomas with the MACOP-B protocol]

BACKGROUND

To investigate the results of the treatment of large-cell non-Hodgkin's lymphomas (LCNHL) with the MACOP-B chemotherapy protocol.

METHODS

20 patients with the following inclusion criteria were treated: LCNHL with a definite majority of large lymphoid cells and absence of previous therapy, HIV infection or severe underlying diseases.

RESULTS

Three patients died during therapy and 15 (75%) achieved a complete remission. Actuarial survival after 36 months (0.66) was significantly better (p = 0.05) than that of a comparable historical series of LCNHL treated with CHOP (0.28). Age, stages III-IV, B symptoms, large lymphatic mass (LLM) and bone marrow infiltration did not negatively affect survival. The toxicity of the MACOP-B protocol was high: mucositis (65%), cytopenia (55%), neuropathy (40%), complications of steroid therapy (15%), and mortality directly related with therapy in 15%. Residual masses were found after therapy in 7% (70%) with BD, which were localized in lymphoid areas or in parenchyma (spleen and kidney). Surgical exploration showed that the residual masses were not tumoral in three cases, and in another three magnetic resonance suggested inactive disease.

CONCLUSIONS

The MACOP-B protocol is highly effective for the treatment of LCNHL. The essential prognostic factor for survival in these NHL appears to be the cell composition with a great majority of large cells.

Non-Hodgkin's lymphoma after prolonged remission of Hodgkin's disease in an HIV-infected patient

Hodgkin's disease was diagnosed in a 22-year-old HIV-seropositive man in 1986. Alternate MOPP/ABVD chemotherapy induced a clinical remission. He was asymptomatic until 3 years later when fever and peripheral and mediastinal lymphadenopathy appeared. Lymph node biopsy showed a large-cell anaplastic lymphoma and EBV genome was identified in the malignant cells, suggesting that transformation might had been induced by EBV. The present case affirms that in patients with HIV-related lymphomas who present enlarging lymphadenopathy after stable remission, the development of lymphomas of higher malignancy needs to be ruled out.