Lymphosarcoma of the lung with monoclonal (IgM) gammopathy. A clinicopathologic, histochemical, immunologic, and ultrastructural study

Primary lung involvement with amyloid deposition in Waldenstrom's macroglobulinemia: Observations from over 20 years

Primary lung involvement in Waldenström's macroglobulinemia (WM) is rare. The present case had lymphoplasmacytic lymphoma, secreting monoclonal IgM, localized to the lung.WM is also of great interest with regard to the pathogenesis of amyloidosis. The nodular, parenchymal amyloid lesions of the lung are presented with CXR observations of more than 20 years.

An overview of monoclonal gammapathies

The neoplastic proliferation of single clones of plasma cells causes synthesis of very large amount of monoclonal immunoglobulins consisting of only one type of heavy either the gamma, alpha, mu, delta or epsilon chain or only kappa or lambda light chains. Each monoclonal immunolobulin differs idiotypically from each other. These monoclonal immunoglobulins are also called paraproteins and are frequently associated with a broad heterogeneous group of plasma cell dyscrasias. Occasionally their presence is observed in a few benign conditions and in old age. In the present review a detailed account of different types of monoclonal gammapathies are described.

Waldenström's macroglobulinemia. Report of an autopsy case presenting with a pulmonary manifestation

An autopsy case of Waldenström's macroglobulinemia is reported, in whom an abnormal pulmonary shadow had already existed 2 years before the diagnosis of the disease and was proved to be pulmonary involvement. Immunoelectrophoresis demonstrated a monoclonal increase in immunoglobulin M with kappa light chain. A chest X-ray film showed a reticulo-nodular shadow in the right lower lobe of the lung. A bronchial biopsy specimen revealed a diffuse and dense lymphocytic infiltration. Bone marrow aspirate revealed no remarkable change except for a slight increase in plasma cells (1.7%) and an appearance of atypical lymphocytes (0.5%). At autopsy, more than half of the right lower lobe of the lung was occupied by a pale whitish, viscid and glossy tumour mass. Heptosplenomegaly and lymph node enlargement were not observed. Histological findings of the tumour tissue were similar to those of the biopsy specimen. Lymphocytic infiltration was observed also in the liver, kidneys, spleen, bone marrow and lymph nodes, but was of minor degree. Other reported cases of Waldenström's macroglobulinemia accompanied by pulmonary involvement are reviewed.

Unusual crystalline inclusions in a case of AIDS-related complex

A lymph node of a patient with AIDS-related complex was studied with light and electron microscopic techniques. In numerous plasma cells and follicular center cells amorphous and unusual crystalline structures which probably consist of abnormal immunoglobulin could be found.

Two cases of pulmonary Waldenström's macroglobulinemia

Two cases of Waldenström's macroglobulinemia (WMG) with principally pulmonary manifestation are presented. The disease in both cases was discovered from abnormal shadow in chest x-ray films, without classic features of the disease such as anemia, lymphadenopathy, hepatosplenomegaly or visual disturbance. Transbronchial biopsy (case 1) and open lung biopsy (case 2) revealed diffuse infiltration of lymphoplasmacytoid cells. In both cases, the cytoplasm of proliferating cells stained for monoclonal IgM by the peroxidase-antiperoxidase method. Immunologic examination revealed that almost all tumor cells obtained from bronchoalveolar lavage fluid (case 1) and cell suspension of the right lung (case 2) had monoclonal surface immunoglobulin for IgM. These data established the diagnosis of pulmonary WMG. These cases indicate the importance of immunologic studies for establishing a diagnosis of pulmonary WMG, since histologic findings in biopsy specimens and clinical features are often not specific enough for making this diagnosis.

Pulmonary lymphomas and other pulmonary lymphoid lesions. A clinicopathologic and immunologic study of 64 patients

Sixty-four patients with lymphoid lesions involving the lung were separated into three groups. In 32 patients, the predominant lymphoid cell population consisted of small, mature-appearing round lymphocytes with or without plasmacytoid features. This group, designated small lymphocytic proliferation (SLP), represents a heterogeneous group of pulmonary lymphocytic lesions including small lymphocytic lymphoma, lymphocytic interstitial pneumonia, and lymphoid hyperplasia (pseudolymphoma). Thirteen SLP patients were identified as having small lymphocytic lymphoma on the basis of monoclonality, progressive disease in other sites, or both. This group was morphologically identical to the remainder of the SLP patients, except for a higher incidence of plasmacytoid features (P = 0.003) and a greater degree of mast cell infiltration (P less than 0.05). Four of these 13 patients subsequently developed an aggressive large cell lymphoma resulting in death in three patients. The median survival for all of the SLP patients has not yet been reached. Patients in whom a monoclonal cell population could be established showed a slightly worse prognosis of borderline statistical significance (P = 0.09); however, the presence of a serum monoclonal gammopathy conveyed a significantly worse prognosis (P = 0.003). The remaining two groups of patients had various forms of malignant lymphoma other than the small lymphocytic type. One group of 12 patients, designated as having presumed primary lymphoma limited to one or both lungs (PL), had a prolonged course with a median survival of 117 months. The remaining 20 patients had disseminated lymphoma also involving lung (DL); DL patients had a shorter median survival of 33 months.

Localized lymphoid nodules of lung. A reappraisal of the lymphoma versus pseudolymphoma dilemma

Eleven patients with localized lymphoid nodules of the lung (LLN) were seen at the Mount Sinai Hospital from 1962-1981. The diagnosis of pseudolymphoma was made in six instances based on the following criteria: (1) solitary or multiple nodules discovered on chest roentgenograms composed of cytologically benign lymphoid cells (small lymphocytes); (2) polymorphic character of the infiltrate, including plasma cells, histiocytes and monocytes; and (3) presence of germinal centers in the lesion. Five lesions were classified as lymphomas and exhibited: (1) solitary or multiple nodules composed of atypical lymphoid cells; (2) absence of germinal centers; (3) lack of mediastinal lymph node involvement. Bronchial and/or pleural infiltration by lymphoid cells was present in lymphomas as well as in pseudolymphomas. Five lesions were studied with immunofluorescent techniques for the presence of intracytoplasmic immunoglobulins and in one pseudolymphoma, lymphocyte marker studies were performed. The procedures were not useful in separating benign from malignant lesions. All patients underwent surgery; three with lymphoma and one with pseudolymphoma received adjuvant chemotherapy. Patients were followed post surgically for up to 13 years. None of the six patients with pseudolymphoma died as a result of their lesions but two had either recurrences or developed extrapulmonary lymphoid lesions. All five lymphoma patients did well. Only one died while on chemotherapy with invasive pulmonary aspergillosis but no tumor. One-hundred and sixty-seven reported cases from the literature are analyzed. Pulmonary pseudolymphomas do not necessarily follow a benign course and malignant lymphomas limited to the lungs do not usually undergo progressive disease. Present pathologic criteria do not allow prediction of recurrence or progression of disease and are not acceptable for determining the advocacy of chemotherapy in patients with LLN.

Lymphoplasmacytic/lymphoplasmacytoid lymphoma: a clinical entity distinct from chronic lymphocytic leukaemia?

Clinical data of 116 patients with chronic lymphocytic leukaemia (CLL) and of 114 patients with lymphoplasmacytic/lymphoplasmacytoid lymphoma (synonym: LP immunocytoma, IC) as diagnosed according to the Kiel classification were compared. This interim evaluation of a prospective multicenter study of the Kiel Lymphoma Study Group characterizes IC the less favorable lymphoma entity as evidenced by a more rapid lymph node enlargement, by a higher incidence of constitutional symptoms and of marked anaemia, and by a higher percentage of patients requiring early treatment. In addition, in IC autoimmune haemolytic anaemia was detected in 11.2% of investigated patients as compared to none of the patients with CLL, and monoclonal gammopathy was disclosed in 34.2% of investigated patients as compared to only three patients with CLL who could be, however, unrecognized cases of IC. Actuarial survival data after a follow-up period of 40 months are in favor of an overall better prognosis of patients with CLL than of patients with IC.

Pulmonary manifestations of Waldenstrom macroglobulinemia

Waldenstrom macroglobulinemia (WMG), a proliferation of malignant monoclonal IgM secreting plasmacytoid lymphocytes in lymph nodes, spleen, and marrow, usually pursues a chronic clinical course. A patient with WMG for five years who developed pulmonary tumors consisting of plasmacytoid lymphocytes prompted a review of the literature for pulmonary manifestations of WMG. Twenty-six males and 18 females, ranging in age from 33 to 84 years, have been reported with histologically proven pulmonary involvement by WMG. The x-ray findings, evident in most patients when first seen, consisted of masses (22 patients), inflitrates (31 patients), and pleural effusions (19 patients). Most patients (24) had two or more of these manifestations but only five, in addition to our patient, had isolated pulmonary nodules. Isolated pulmonary infiltrates were found in ten patients and isolated pleural effusions in only four. Symptoms at the onset of pulmonary involvement included dyspnea (54%), nonproductive cough (33%), and chest pain (7%); 15% were asymptomatic. Pulmonary manifestations, like other features of WMG, respond to alkylating agents or irradiation and do not appear to affect prognosis adversely. Pulmonary involvement should be suspected in any patient with WMG who develops an abnormal chest x-ray.