Inoperable plasma cell granuloma of the heart: spontaneous decrease in size during an 11-month period

Plasma cell granuloma occurs in children, typically as an intrapulmonary mass. Surgical excision is the treatment of choice and is usually curative. We report an atypical and unresectable plasma cell granuloma that occurred asymptomatically in the heart of a child and spontaneously decreased in size by 40% during an 11-month period. Thus, plasma cell granuloma should be considered in the differential diagnosis of any child who has a cardiac mass. Observation should be considered a treatment option because this case demonstrated that the cardiac mass can spontaneously recede without therapy.

Subungual keratoacanthoma. Report of a case and review of the literature

Subungual keratoacanthoma (SUKA) is an uncommon and clinically distinctive tumor of the nail bed. It can easily be confused with well-differentiated subungual squamous cell carcinoma. Distinguishing features of SUKA include pain, rapid growth, and early underlying bony destruction. Unlike keratoacanthomas arising from sun-exposed skin, SUKAs seldom resolve spontaneously and are more locally destructive. Of 18 cases reported in the literature, five patients have developed recurrent disease, all within five months of the initial surgery. We describe a patient with SUKA initially treated by curettage followed two days later by a conservative amputation that revealed conspicuous residual keratoacanthoma. The deep, burrowing tendency of SUKA and the intimate association with underlying bone may explain the reported tendency for recurrence after curettage.

Central nervous system lymphoma: histologic types and CT appearance

The distribution of histologic types of lymphoma according to the proposed working formulation was determined for 55 patients with primary central nervous system (CNS) non-Hodgkin lymphoma. Fifty-five percent of these patients had diffuse large-cell histologic features. When the relationship between histologic type and computed tomographic (CT) appearance was analyzed, the following trends were noted: A greater percentage of mixed cell tumors were multiple when compared with other types; noncleaved small-cell tumors were more commonly located in the central gray matter or corpus callosum than were other types; all immunoblastic tumors were enhanced homogeneously, unlike other types; and smaller tumors appeared to be associated with an increased histologic grade. Eleven patients had CT confirmation of a CNS recurrence; in eight patients, the recurrent tumor was in a different location than the original lesion. Eleven patients had associated intraocular lymphoma, and four were immunosuppressed.

Patterns of failure in primary testicular non-Hodgkin's lymphoma

Patterns of failure were analyzed in 30 patients with testicular non-Hodgkin's lymphoma: 16 had stage IE disease, ten had stage IIE, and four had stage IV. After orchiectomy, two of the 16 patients with stage IE disease received no additional therapy, one received multiagent chemotherapy, and 13 received pelvic and para-aortic radiation. Twelve patients with stage IE disease had progression, and the median time to progression was 12 months. Of the 14 patients with extratesticular involvement (stage IIE or IV), one (stage IV) received no treatment after orchiectomy, three (stage IIE) received para-aortic and pelvic radiation, and ten (seven stage IIE and three stage IV) received multiagent chemotherapy with or without radiation. Eight of the patients with stage IIE or IV disease had progression, and the median time to progression was 11 months. Widespread extranodal progression was observed in 17 of the 20 patients who had progression. The tendency of testicular lymphoma for early systemic progression suggests a need for multiagent chemotherapy in initial management.

Splenic hematopoiesis in polycythemia vera. A morphologic and immunohistologic study

Spleens from 42 patients with polycythemia vera were studied with immunohistologic technics to assess the degree of hematopoietic cellularity in an attempt to clarify the pathogenesis of the splenomegaly characteristic of this disorder. The 22 spleens obtained in the erythrocytotic phase showed striking congestion with mature erythrocytes but no significant extramedullary hematopoiesis. However, the 20 spleens obtained in the spent phase showed prominent trilinear extramedullary hematopoiesis. Increasing splenomegaly with extramedullary hematopoiesis correlated with the development of increased medullary reticulin and peripheral blood leukoerythroblastosis. Splenic myeloid metaplasia is not a feature of uncomplicated polycythemia vera, and its presence indicates progression to the spent phase, or postpolycythemic myeloid metaplasia. The authors' findings indicate that the presence of hematopoietic precursors in the spleen in the spent phase of polycythemia vera and in agnogenic myeloid metaplasia is a result of their filtration from the peripheral blood.

Oncogene expression in T-cell lymphoproliferative disorders

We have investigated the expression of oncogenes and other related genes in eleven patients with T-cell lymphoproliferative disorders and ten patients with other hematologic malignancies. The phenotypes of the T-cell disorders were determined using monoclonal antibodies specific for helper or suppressor subsets. RNA preparations were isolated from peripheral blood mononuclear cells and/or lymph node sections, 5'-end labeled with gamma-32P-ATP, and hybridized under stringent conditions to an excess of nitrocellulose-bound specific cloned DNA; autoradiographs were analysed by microdensitometry. Results revealed increased expression of K-ras, v-fps, transferrin receptor, alpha-tubulin and alpha-interferon in at least five of six helper T-cell lymphoproliferative disorders, while five of five suppressor T-cell disorders demonstrated levels of hybridization to these clones no higher than background. However, studies of T-suppressor disorders demonstrated enhanced levels of beta-interferon-specific RNA in five of five patients, an increase apparent in three of six T-helper chronic lymphoproliferative disorders. These results demonstrate different patterns of gene expression evident in T-helper and T-suppressor abnormalities.

Megakaryoblastic transformation of chronic granulocytic leukemia

Three cases of megakaryoblastic transformation of chronic granulocytic leukemia (CGL) are reported. In each case, the leukemic transformation had morphologic features suggesting megakaryocytic differentiation. This was confirmed by positive immunostaining with a monoclonal antibody (HP1-1D) specific for platelet and megakaryocyte glycoprotein IIb/IIIa antigen, which was expressed by the majority of the leukemic blasts in all three cases. Cases with evidence of multilineage differentiation of the leukemic transformation were excluded. A striking feature in two patients was the manifestation of lytic bone lesions and soft tissue masses at presentation. A biopsy of a lytic bone lesion and soft tissue mass in one patient revealed a megakaryoblastic leukemic infiltrate, which by immunocytochemical staining was positive for the megakaryocytic markers, glycoprotein IIb/IIIa antigen, and Factor VIII (von Willebrand factor) antigen. In contrast to granulocytic sarcomas, the megakaryoblastic sarcoma did not stain cytochemically for chloroacetate esterase. The mean survival after acute transformation was 5.3 months. The three cases of megakaryoblastic transformation represented a significant proportion of all CGL blastic transformation cases (ten cases) evaluated by bone marrow examination in our institution during a 13-month period. Megakaryoblastic transformation of CGL may occur more frequently than has been appreciated, and can present as lytic bone lesions or as soft tissue megakaryoblastic sarcomas.

Computer-assisted stereotaxic biopsy for the diagnosis of primary central nervous system lymphoma

Primary CNS lymphoma was diagnosed in 13 patients after stereotaxic biopsy of indeterminate intracerebral mass lesions. Two patients also had laser extirpation of CT-visible tumor. The group consisted of 10 men and 3 women, aged 17 to 81 (mean, 55 years; median, 60 years). The lesions on CT were characteristically hyperdense, homogeneously contrast-enhancing, and associated with mild to moderate mass effect. Five patients had more than one lesion visible on CT. Complete staging procedures for occult systemic lymphoma were negative in all 13 patients. The majority (eight) of the tumors were of the diffuse, large-cell type. Five biopsy specimens underwent special immunostaining as a supplemental diagnostic effort. Two patients with small lymphocytic tumors demonstrated features consistent with T cell phenotype. Two patients with diffuse, large-cell tumors were confirmed as B cell phenotype by monotypic immunoglobulin light chain content. Primary CNS lymphomas represent a treatable group of primary brain tumors. Because of their tendency to develop in deep cerebral regions, they are often inaccessible to conventional neurosurgical techniques. We propose that stereotaxic neurosurgery can provide safe and accurate diagnosis, which is a prelude to planning comprehensive management.

Abdominal Burkitt's lymphoma: role of early aggressive surgery

Current surgical teaching advocates debulking of the abdominal Burkitt's lymphoma to decrease tumor burden and improve survival. The records of 16 children who had Burkitt's lymphoma were reviewed. Eleven of these children presented with abdominal tumors. Five of these 11 patients are long-term survivors and six have died. Three of the tumors were primarily resected; two were in patients who became long-term survivors. One resection was complicated by acute renal failure, leading to the early demise of the patient. Four tumors were debulked; only one of these was in a long-term survivor. Acute renal failure also complicated the hospital course in one of these children. Finally, four patients underwent initial incisional biopsies and plans were made for subsequent resection of any residual tumor 6 weeks later. Two of these children survived and two have died. The results of this pilot study do not confirm that there is a clear advantage to aggressive operative cytoreduction. Although this approach decreases the total tumor burden, it may also impose severe metabolic complications and postpone the administration of chemotherapy. These results do suggest the need for a multi-institutional review of the surgical management of abdominal Burkitt's lymphoma.

Cytokeratin expression in smooth muscle and smooth muscle tumours

The expression of cytokeratin intermediate filaments by a tumour has been accepted as evidence of an epithelial origin. Although there have been anecdotal reports of cytokeratin expression within tissues and neoplasms of non-epithelial origin, particularly muscle, there have been no comprehensive studies of its frequency and distribution. In order to investigate this we have studied 51 cases of normal smooth muscle and benign and malignant smooth muscle tumours using a panel of monoclonal antibodies against a range of intermediate filaments (cytokeratins, desmin and vimentin). Cytokeratin expression was noted overall in 50% of normal, benign and malignant smooth muscle tissues. Such expression tended to have a focal or patchy distribution. No case expressed cytokeratins in the absence of both desmin and vimentin. The implication of these findings for diagnostic immunocytochemistry is that intermediate filaments alone are not completely reliable markers of tumour histogenesis and should be used as part of a larger panel of monoclonal antibodies.

Primary extranodal soft tissue lymphoma of the extremities

Since true primary lymphomas of soft tissues are extremely rare and there are few well-documented cases in the literature, we report eight cases to help define the clinical and pathologic features of this type of extranodal lymphoma. Among 7,000 malignant lymphomas seen at Mayo Clinic over a 10-year period, we found eight cases of Stage IAE extranodal malignant lymphoma that presented as a soft tissue mass in the upper or lower extremities. The tumors occurred in the following sites: thigh (n = 4), upper arm (n = 2), ankle (n = 1), and calf (n = 1). Two cases had low-grade histology: small lymphocytic lymphoma and follicular mixed small-cleaved and large-cell lymphoma. An intermediate-grade histology was present in two cases: diffuse mixed small- and large-cell lymphoma and diffuse large-cell (cleaved) lymphoma. Half of the patients had a high-grade lymphoma: diffuse large-cell (n = 3) and large-cell, immunoblastic (n = 1). The results of immunohistochemistry and electron microscopy in selected cases are discussed in the context of the differential diagnosis with other small, round-cell cancers. Four patients died of recurrent lymphoma, one at 7 months, two at 15 months, and one at 4 years. Three patients are alive without evidence of disease at 3, 8, and 13 years. One patient is alive and is receiving chemotherapy for locally recurrent lymphoma 6 months after diagnosis.

Blastic variant of hairy-cell leukemia

Three patients with hairy-cell leukemia presented with an unusual combination of clinical and cytologic features. Clinical manifestations included constitutional symptoms, progressive left upper abdomen discomfort, and lymphadenopathy. All three had pancytopenia. Bone marrow aspirate was hypercellular, with extensive replacement by abnormal blastic mononuclear cells with a high nuclear/cytoplasmic ratio. Round, oval, or indented nuclei, with reticular chromatin and prominent nucleoli, and basophilic cytoplasm, with abundant large azurophilic granules, were noted. The bone marrow biopsy specimen showed diffuse involvement in two patients and patchy involvement in one, with absence of fibrosis. The abnormal cells were intensely positive by tartrate-resistant acid phosphatase stain. All of the patients responded well initially to splenectomy. One, who presented with multiple chromosomal abnormalities, had a relatively short survival. The other two are alive. One started therapy with chlorambucil 21 months after operation, and the other presented in a hyperleukocytotic phase five years after operation and responded dramatically to 2'-deoxycoformycin.

Immunohistologic labeling as an indicator of liver allograft rejection

Monoclonal antibodies were used to identify T-helper cells (TH) and T-suppressor/cytotoxic cells (TS/C) in biopsy specimens obtained 7, 21, 90, 180, and 365 days postoperatively, and during episodes of graft dysfunction, from 34 consecutive liver transplant patients treated with cyclosporine and steroids. Rejection was diagnosed by the presence of appropriate laboratory and light microscopic findings and at least 8 weeks of follow-up to exclude other causes of graft dysfunction. Four immunohistologic patterns were seen--no labeled cells (No), only lobular TS/C, only portal TH, and a portal mixture of TH and TS/C (mix). Of 36 specimens with the No or only lobular TS/C pattern, 29 were not associated with rejection. Of the 39 specimens with the portal TH or portal Mix pattern, 33 were associated with a rejection episode. In addition, in nine specimens from patients with no biochemical or routine histologic evidence of rejection, the presence of portal TH or a portal mix indicated immunologic rejection 5 days to 5 weeks before biochemical and routine histologic evidence of it was manifested. Immunohistologic labeling appears to be an early indicator of liver allograft rejection.

Malignant lymphoma of bone

A total of 422 patients with malignant lymphoma of bone who were seen at the Mayo Clinic from 1907 through 1982 were placed into four major groups based on stage of disease. There was one group with primary lymphoma of bone, one group with multifocal osseous lymphoma, and two groups with lymphoma of bone and nodal or soft tissue (or both) disease. The last-mentioned two groups were separated on the basis of time of onset of osseous lymphoma in relation to the nonosseous disease. The stage of disease was the single most important prognostic indicator of overall survival in malignant lymphoma of bone. The 5- and 10-year survival rates were, respectively, 58% and 53% for patients with primary bone lymphoma, 22% and 12.5% for patients with bone and nodal or soft tissue (or both) disease, and 42% and 35% for patients with multifocal osseous disease. Features having no significant prognostic value were sex of the patient, histologic grade of the lymphoma (according to the Working Formulation and the Kiel system), and presence of T-cell features or cleaved cells (or both). This study is not able to adequately address efficacy of treatment. In fact, treatment may be very important in outcome.

Mast cell leukemia: report of a case and review of the literature

We report the clinical and pathologic findings in one case of mast cell leukemia observed in a series of 60 patients with systemic mast cell disease. The leukemic variant of systemic mast cell disease is rapidly fatal (mean duration of survival, less than 6 months) in contrast to most nonleukemic cases, which follow an indolent clinical course. On the basis of our case and eight previously reported cases, mast cell leukemia is characterized by a substantial increase in atypical mast cells in the peripheral blood, diffuse infiltration with atypical mast cells in the bone marrow, a strong association with peptic ulcer disease, prominent constitutional symptoms, and hepatosplenomegaly. These cases should be distinguished from malignant mastocytosis without a substantial number of circulating atypical mast cells and also cases of acute nonlymphocytic leukemia that arise in the background of systemic mast cell disease.

Extracellular deposition of eosinophil granule major basic protein in lymph nodes of patients with Hodgkin's disease

Lymph nodes from each of the four histologic types of Hodgkin's disease were examined for the presence of eosinophils and for eosinophil degranulation by immunofluorescent localization of eosinophil granule major basic protein (MBP). Eosinophil degranulation shown by MBP deposition outside of eosinophils was found in six of eight nodes from patients with nodular sclerosing disease and in two of eight nodes from patients with lymphocyte depletion-type disease. Three nodes of the mixed cellularity type, one node of the lymphocyte predominance type, and one lymph node of the lymphocyte depletion type showed one or two small foci of extracellular MBP deposition. Lymph nodes from patients without Hodgkin's disease showed no extracellular deposition of MBP. Large numbers of eosinophils were found in seven of eight nodes of the nodular sclerosing variant, but were less frequently seen among the other types of Hodgkin's disease. The presence of extracellular MBP in lymph nodes of patients with Hodgkin's disease indicates that eosinophil degranulation commonly occurs and suggests that the released eosinophil granule proteins may participate in the inflammatory reaction in this disorder more extensively than is presently appreciated.

Plasma cell orificial mucositis. Report of a case and review of the literature

Plasma cell orificial mucositis is a benign idiopathic condition of orificial mucous membranes, characterized histopathologically by a dense plasmacytic infiltrate. Although plasma cell orificial mucositis was originally described by Zoon as occurring on the glans penis, conditions similar to plasma cell orificial mucositis involving other body orifices have been reported under various names. A patient with involvement of the lips and epiglottis associated with psoriasis and fissured tongue is described. Plasma cell orificial mucositis must be differentiated from numerous other entities, including erythroplasia of Queyrat, allergic contact mucositis, plasmacytoma, plasmoacanthoma, syphilis, candidiasis, and cheilitis granulomatosa.

Malignant lymphoma in Olmsted County, Minnesota, 1970 through 1977

A study of the incidence of malignant lymphoma in Olmsted County, Minnesota, revealed 91 new cases during the period 1970 through 1977. On the basis of the analyzed data, the overall average annual incidence rate per 100,000 population was 12.2 for males and 14.2 for females. The rates for both sexes combined (unadjusted for age) were 1.5 for Hodgkin's disease, 6.2 for lymphosarcoma, and 5.5 for reticulum cell sarcoma. The incidence rate for Hodgkin's disease decreased insignificantly, whereas that for both lymphosarcoma and reticulum cell sarcoma increased significantly during the period 1970 through 1977 in comparison with rates from the period 1945 through 1969. The largest increase was for rural males, for whom the rates for all three histologic types of lymphoma were substantially higher than those for urban males.

Non-Hodgkin's lymphoma associated with hypercalcemia and increased activity of serum angiotensin-converting enzyme

We describe two patients with diffuse non-Hodgkin's lymphoma, hypercalcemia, and increased activity of serum angiotensin-converting enzyme. A mechanism similar to that operative in sarcoidosis is speculated to have caused the hypercalcemia. A lymphokine elaborated by the malignant lymphoma may cause activated macrophages to produce 1,25-dihydroxyvitamin D3.