Lymphomatoid granulomatosis of the skin: light microscopic and ultrastructural studies

Radiation therapy in lymphomatoid granulomatosis

A 59-year-old woman with lymphomatoid granulomatosis (LYG) involving the lungs and skin is reported. This patient had many large, ulcerated cutaneous lesions that progressed during prednisone and cyclophosphamide therapy. However, the cutaneous disease responded to radiation treatment in terms of relief of symptoms and objective evidence of subsidence of local disease. The patient died of an unrelated cause 2 years after the establishment of the diagnosis of LYG. At autopsy, the skin lesions were completely healed, with no residual disease. However, there was evidence of the progression of LYG into a malignant large cell lymphoma involving the liver and lung. A discussion of the nature of LYG and the role of radiotherapy in localized disease is presented.

Lethal midline granuloma (polymorphic reticulosis) and lymphomatoid granulomatosis. Evidence for a monoclonal T-cell lymphoproliferative disorder

Lymphomatoid granulomatosis (LG) and polymorphic reticulosis (PR), originally described as distinct entities, now are considered as a single disease process. Common histopathologic features include necrosis, vasculitis, and a granulomatous infiltrate. Such features have led to consider lymphomatoid granulomatosis as a systemic vasculitis; alternatively the possible emergence of an overt lymphoma has suggested that it could be a lymphoproliferative process. To investigate this later hypothesis, the authors analyzed the cellular infiltrate of tissue specimens from two patients with histologic features of LG. The analysis included the study of T-cell antigen expression and DNA rearrangement of the beta T-cell receptor gene. In one patient, the T-cell phenotype of infiltrating cells was abnormal because of antigen loss. In both patients, the cells contained rearranged DNA indicating the presence of a clonal T-cell proliferation. It is concluded that some cases of LG and PR, if not all, are related to a neoplastic T-cell lymphoproliferative disorder.

Immunohistochemical and ultrastructural studies on disseminated skin lesions of midline malignant reticulosis

Midline malignant reticulosis (MMR), a disease included in the lethal midline granuloma, is histologically characterized by a mixture of lymphoid cells and atypical reticulum cells. Recent investigations of the nature of proliferating cells in MMR have suggested different conclusions, i.e., that the lesion is a true histiocytic, B- or T-cell. Two cases of MMR are presented, on which extensive laboratory studies were carried out. The results showed that the atypical reticulum cells were negative when stained immunohistochemically with monoclonal antibodies for T- or B-cells, diffusely stained by reactions for acid phosphatase and alpha-naphthyl acetate esterase, positively stained with human lysozyme and alpha-1-antitrypsin, and possess abundant cytoplasm containing primary lysosomes, polylysosomes and residual bodies. These findings indicate the true histiocytic nature of the proliferating cells in MMR.

Cutaneous granulomatous vasculitis: its relationship to systemic disease

Microscopic and medical review of twenty-six patients with skin biopsy specimens that showed granulomatous vasculitis demonstrated vascular histiocytic granulomas with fibrinoid destruction of blood vessels in the dermis and panniculus. Cultures of the biopsy specimens were nonspecific. The skin lesions varied from erythema to papulonodular and vesicular eruptions; they were usually on the extremities but also involved the trunk. Eight patients had systemic lymphoproliferative diseases: three, lymphoma; two, angioimmunoblastic lymphadenopathy; two, preleukemia; and one, chronic granulocytic leukemia. Five of these eight patients died within 2 years after the onset of skin lesions. The four patients with systemic vasculitis died within 1 year after the onset of skin lesions. Five patients with arthritis, four with gastrointestinal disease, three with systemic sarcoidosis or sarcoidlike disease, and one with tuberculosis had a more favorable prognosis. The histologic pattern of cutaneous nonlymphomatoid granulomatous vasculitis is associated with significant systemic disease, especially lymphoproliferative disorders. Patients with lymphoproliferative disorders or systemic vasculitis have a much poorer prognosis than those with inflammatory or infectious granulomatous disease.

Pulmonary polymorphic centroblastic type malignant lymphoma in a patient with lymphomatoid granulomatosis, Sjögren syndrome and other manifestations of a dysimmune state

A case of lymphomatoid granulomatosis arising in a patient with a long history of dysimmunity is reported. The autopsy reviewed the final evolution into a high grade malignant lymphoma with IgM K immunoglobulin production and discovered in deep lymph nodes modifications similar to angio-immunoblastic lymphadenopathy.

Lymphomatoid granulomatosis. Light microscopic, electron microscopic and immunohistochemical study

A case of lymphomatoid granulomatosis (LYG) involving the lungs, skin, stomach, and possibly the left kidney in a 60-year-old man is presented. The infiltrates in the lungs, stomach, and skin showed a polymorphic appearance, and consisted predominantly of lymphocytes of mature and blastic form and of a few neutrophils, plasma cells, and histiocytes. Most lymphoid cells showed irregularly shaped nuclei and clustered dense bodies, characteristics indicative of T lymphocytes. An immunohistochemical study confirmed the T cell origin of the lymphocytes; i.e. they were positive for Leu-1, Leu-3a and Ia-like antigens but negative for Leu-2a antigen and the antibodies against light chains. The homogeneity of the major population of infiltrates in LYG indicates that at least some forms of LYG may be neoplastic or pre-neoplastic lymphocytic disorders which may ultimately progress to malignant lymphoma.

Systemic histiocytosis of Bernese mountain dogs

A histiocytic proliferative disorder was identified in six closely related Bernese mountain dogs. Clinical signs included anorexia, weight loss, stertorous respiration, and conjunctivitis with marked chemosis. Multiple cutaneous nodules were distributed over the entire body but were especially prevalent in the scrotum, nasal apex, nasal planum, and eyelids. Lesions consisted of perivascular infiltrates of large histiocytes as well as minor populations of lymphocytes, neutrophils, and eosinophils. Histiocytes were further characterized by enzyme histochemistry and electron microscopy. Necropsy examinations of four dogs revealed that the histiocytic infiltrates were widespread and involved skin, lung, liver, bone marrow, spleen, lymph nodes, kidneys, testes, orbital tissues, and others. However, skin and peripheral lymph nodes were more consistently involved. The disease course was punctuated by remissions and relapses not clearly influenced by conventional therapeutic measures. Preliminary results of an experimental therapeutic regimen involving administration of bovine thymic extracts in two dogs are present. The relationship of the disorder to other human and canine histiocytic proliferative disorders is discussed.

Cutaneous lymphomatoid granulomatosis: a rare cause of recurrent skin ulceration

We report the case of a 34-year-old male who presented with recurrent skin ulceration due to lymphomatoid granulomatosis. Monoclonal antibody studies showed a high T helper (T4):T suppressor (T8) cell ratio in both the lesions and the peripheral blood. Plasma cells in the infiltrate showed IgA lambda staining but as yet no monoclonal immunoglobulin has been identified in the blood or urine. Lymphocytes bearing markers of immature cells (T10) were observed in the tissue and blood.

Syringolymphoid hyperplasia with alopecia

A 26-year-old man presented with an unusual skin lesion consisting of a hairless area on the left leg studded with reddish-brown papules, together with follicular hyperkeratosis and circumscribed anhidrosis. Skin biopsies showed dense lymphocytic infiltrates in the dermis and around hyperplastic sweat ducts and glands. Similar clinical and histological features have been described in two previous case reports. We propose the term syringolymphoid hyperplasia with alopecia for this unusual skin disease.

T cell lymphoma presenting clinical and morphological features resembling polymorphic reticulosis and lymphomatoid granulomatosis

A male, 53 years old, complained of a mass on the left side of neck. The biopsy specimens revealed extensive necrotizing lesions with polymorphonuclear leukocyte infiltration. About three years later a recurrence from the same site was noted and the rebiopsy specimens showed features of malignant lymphoma of pleomorphic type. Subsequently multiple cutaneous nodules and then ulcerative lesions of the midfacial region developed and repeated biopsies were done. Immunological examination indicated that the lymphoid cells obtained from the skin lesion had predominantly T-lymphocyte marker. He died of massive hemorrhage from the nasopharyngeal lesion 51 months after the first admission. Autopsy revealed multiple organ involvements, including the nasopharynx, lungs, subcutaneous tissue, and adrenal gland. The morphological features in the present case were compatible with a diagnosis of lymphomatoid granulomatosis or polymorphic reticulosis (midline malignant reticulosis), and were thought to be best designated as T cell lymphoma.

Lymphomatoid granulomatosis (Liebow)

An autopsy case with pulmonary lesions analogous to Liebow's lymphomatoid granulomatosis (LYG) and some other unusual pictures were reported. A 29-year-old male who had been diagnosed and treated as Sjögren's syndrome for eleven years because of intermittent swelling of the parotids with diffuse lymphoid cell infiltration and positive serum RA-test, showed several circumscribed densities on the chest X-ray examination which were deemed to be of interlobar pleurisy. On autopsy, the nodular lesions in the lung were composed of angiocentric-angiodestructive lymphoid cell proliferation analogous to LYG. In addition, the present case was characterized by focal glomerulonephritis and splenic trabeculitis which are quite unusual associations in LYG. The relationships of the present case to other similar diseases such as Wegener's granulomatosis, Sjögren's syndrome, primary lymphoma of the lung, etc. were discussed.

Biopsy findings in malignant histiocytosis presenting as lethal midline granuloma

Nasal biopsy findings in malignant histiocytosis presenting clinically as lethal midline granuloma are characterised by necrosis and infiltration of atypical histiocytic cells with a diffuse positive reaction for non-specific esterase. This cellular character was common to midline malignant reticulosis, and midline malignant reticulosis and malignant histiocytosis are thought to be the same disease. Patterns of histiocytic infiltration in the nasal lesions of 19 cases are reported in this paper. Polymorphic and monomorphic patterns were observed in 11 and four cases respectively, on the initial biopsy, but subsequently the infiltrates frequently became monomorphic on serial biopsy. The reverse was not observed. Surface marker and cytochemical studies showed the true histiocytic nature of the proliferating cells, and necropsy findings justified the diagnosis of malignant histiocytosis.

Lymphomatoid granulomatosis: an analysis of clinical and immunologic characteristics

Six patients with lymphomatoid granulomatosis were studied. Two patients had eye involvement, a rare manifestation of this disease. Both had complete disappearance of disease in this area after radiation therapy. One patient presented with an autoimmune hemolytic anemia, which remitted completely with chemotherapy. The use of corticosteroids or chemotherapy was effective in bringing about a decrease in pulmonary infiltrates in all six patients, although the duration of response was limited. One patient did have a prolonged period of clinical remission, and died of an unrelated cause. Evidence of profound immunologic abnormalities was found in these patients by a variety of tests. The extensive immunologic dysfunction present in patients with lymphomatoid granulomatosis has not previously been described. Most strikingly, patients with lymphomatoid granulomatosis have a severe impairment in T-lymphocyte function, confirmed by their inability to react to common skin test antigens or dinitrochlorobenzene, decreased in vitro lymphocyte responsiveness to mitogens and antigens and changes in T-cell subset populations. This may account for the frequent development of malignant lymphomas in patients with this condition.

A procedure for investigating cancer cluster reports

Cancer clusters are described as epidemiologic leads to environmental determinants of cancer. A historical perspective of cancer cluster reports is offered with comments on the various investigative methods. A specific, systematic protocol for responding to cancer cluster reports is offered with a detailed example. Suggestions for decision making and comments on statistical analysis are also offered. Emphasis is placed on the participant interview and on the use of non-case data.

Lymphomatoid granulomatosis-like lesions in a child with leukemia in remission

This case report describes an eight year old leukemic child who was in remission for four and one-half years and showed hypogammaglobulinemia and deficient leukocyte chemotaxis and migration. She developed pulmonary lesions with laryngeal and tracheobronchial disease and died from pulmonary hemorrhage. The lesions found at autopsy were lymphomatoid granulomatosis-like, but were atypical in their anatomic distribution, behavior, and histologic features.

Polymorphic reticulosis (lethal midline granuloma) and lymphomatoid granulomatosis: identical or distinct entities?

Two cases of polymorphic reticulosis were studied. Both cases had a fatal clinical course, that of the second case being rapid and progressive and ending 6 months after the onset of the disease with little demonstrable effect of steroid therapy. Biopsy material was obtained in both patients, and both were submitted to a post-mortem examination. The first case showed typical angiocentric, angiodestructive, polymorphous lymphoreticular infiltrates, involving the pharyngeal region and the tongue. The second case demonstrated these same lesions in the midfacial region, the lungs and the skin. A possible identify between polymorphic reticulosis and lymphomatoid granulomatosis is discussed (because of the coexistence of identical lesions in the midfacial region and in the lung parenchyma in the second case). Wegener's granulomatosis in limited and disseminated forms and malignant lymphoma are considered in the differential diagnosis.

Malignant pulmonary lymphoproliferative angiitis. A monoclonal neoplasm

A 55-year-old female developed a rapidly fatal, infiltrative, bilateral pulmonary disease. Open lung biopsy and subsequent autopsy revealed diffuse involvement by a malignant lymphoproliferative condition showing a striking angiocentric and angioinvasive pattern. This feature, together with microscopic involvement of hilar lymph nodes, bone marrow, spleen, and other viscera suggested lymphomatous transformation of lymphomatoid granulomatosis (LYG). The paucity of necrosis and of the typical polymorphic infiltrate was at variance with the classical description of that condition; however, the bilaterality of the process and the distinctive angioinvasive growth pattern were unlike the typical primary pulmonary lymphoma. Plasmacytoid cells were observed both by light and electron microscopy. Immunohistochemicl evaluation characterized this disease as a monoclonal lymphoproliferative malignancy.

Giant pseudomalignant granuloma

A patient who developed rapidly growing, multicentric, cutaneous tumors clinically resembling pyogenic granuloma is reported. In spite of the fact that the local lesions expanded rapidly and contained cytologically "malignant" cells which appeared to invade dermal vessels, the patient had a benign clinical course. The differential diagnosis of "giant pseudomalignant granuloma" is discussed.

Pulmonary lymphomatoid granulomatosis with immunodeficiency terminating as malignant lymphoma

Lymphomatoid granulomatosis was diagnosed in a 60-yr-old woman 2 yr after presentation with a multi-system disorder resembling sarcoidosis. Five months later autopsy revealed malignant lymphoma. Large aggregates of intracytoplasmic tubular structures resembling nucleocapsid material of the paramyxovirus group were found within cells of lymphoma deposits in the liver. Sequential immunological studies over more than 2 years demonstrated a relatively stable T-cell deficiency associated with variable B-cell dysfunction. The latter was characterized by the production of immunoglobulins of restricted electrophoretic mobility. Intermittent hypercalcaemia was associated with increases in serum IgG and appeared to be due to the presence of Ca-binding paraproteins. It is suggested that lymphomatoid granulomatosis may be a pre-malignant lymphoproliferation, with immune deficiency as a predisposing cause. The pattern of immunological abnormalities suggests that the lymphoma may have been due to B-cell malignant transformation.

Lymphomatoid granulomatosis: a clinicopathologic study of 152 cases

A retrospective study of 152 cases of lymphomatoid granulomatosis (LYG) was undertaken to expand current knowledge about clinical manifestations and therapy, and to identify prognostic indicators in this disease. The major clinical and radiographic features and extra-pulmonary sites of involvement noted in previous studies were essentially confirmed in our study. Adverse prognostic factors included neurologic manifestations, and large numbers of atypical lymphoreticular cells within the pulmonary infiltrate. Unilateral chest lesions and large numbers of small lymphocytes and histiocytes within the infiltrate were associated with a better prognosis. Malignant lymphoma involving lymph nodes developed in 12% of patients. Almost two-thirds of patients have died and the median survival was only 14 months. No particular mode of therapy was found to be satisfactory for LYG, although there was some suggestion that corticosteroids may be useful. Randomized prospective studies are necessary for definitive recommendations regarding therapy.

Radiation therapy in lymphomatoid granulomatosis

Two female patients with lymphomatoid granulomatosis have received radiation therapy for local, progressive, symptomatic lesions. One patient was a 56-year-old woman with concomitant brain and pulmonary lesions which progressed on cyclophosphamide and prednisone therapy. The second patient was a 62-year-old woman with a supraorbital mass which appeared and progressed on prednisone therapy. Both patients exhibited rapid response to radiation therapy, in terms of relief of symptoms and objective evidence of subsidence of local disease. A discussion of the nature of lymphomatoid granulomatosis and its treatment is presented with a review of the literature. One hundred sixty-five cases have now been described including the two in this study, and in only one previous case was radiation therapy utilized to treat local disease, prior to the two cases described herein.

Lymphomatoid granulomatosis. Report of a case and review of the literature

A 24 year old man had a nonproductive cough and chest pain. Chest roentgenogram showed a diffuse infiltrate, and pulmonary function studies showed restrictive lung disease. Extremity weakness, deteriorating mental status and neuropathy progressed as pulmonary findings diminished on corticosteroid therapy. Lung biopsy showed lymphomatoid granulomatosis. The neurologic status deteriorated despite treatment with Cytoxan, intrathecal methotrexate and brain irradiation. Autopsy showed mass lesions of lymphomatoid granulomatosis in the brain and healed lesions in the lungs. A review of the neurologic and pulmonary findings in reported cases show that diminution of pulmonary disease with progression of neurologic disease manifest by mass lesion is unusual. Since the etiology, prognosis and prevalence of this disease remains undefined, all patients with this disease should be reported on.

Lymphomatoid granulomatosis: report of a case without pulmonary lesions and with ischemic colitis, probably a sequel to granulomatosis

This article describes a case of lymphomatoid granulomatosis without active pulmonary involvement of stigmata of healed granulomatous lesions in the lungs. The patient had ischemic segmental colitis due to mesenteric arterial intimal fibrosis, which we interpreted as spontaneously regressed granulomatous involvement of the mesentery. The report deals with the lack of pulmonary involvement and regression of lesions in lymphomatoid granulomatosis.

Malignant fibrous histiocytoma. An electron microscopic study

Sixteen cases of malignant fibrous histiocytoma are presented. Electron microscopy of 15 cases demonstrated fibroblast-like and mononuclear and multinucleated histiocyte-like cells. A small capillary was at the center of all storiform areas examined. Ultrastructural examination can be diagnostically useful within the context of a narrow differential diagnosis by conventional microscopy and the ability, by electron microscopy, to eliminate other mesenchymal cell types. In 13 cases, follow-up information was available from 18 months to 9 years following histological diagnosis. Five patients are alive and 8 patients have died, including two non-tumor related deaths. In 3 cases follow-up was less than 4 months. The biologic behavior of the tumor in this series was generally not related to histopathological parameters. The issue of histogenesis is largely unresolvable. Ultrastructural studies of various types of fibrous histiocytomas, suggesting cells of origin other than histiocytes, give credence to the concept that the histiocyte may represent a morphologic state of a given mesenchymal cell rather than a particular cell type.

Lymphomatoid granulomatosis with cerebral involvement. Light and electron microscopic study of a case

Light and EM study of a case of lymphomatoid granulomatosis revealed a pleomorphic lymphoreticular cell infiltrate, angitis and necrosis with involvement of the brain, lungs, skin and right ear of a 30 year old woman. Cells comprising the infiltrate were classified as lymphocytoid, plasmacytoid, immunoblastic (histocytic) and phagocytic. A number of elements partook of the ultrastructural features of two cell types and were considered to be intermediate forms (plasmacytoid lymphocytes, lymphocytoid immunoblasts, and plasmacytoid immunoblasts). It is believed that the various cell elements form part of a wide spectrum in which transformation of cell types takes place by maturation. This suggests an immunologic process as the main pathogenetic factor in the development of LG.

Lymphomatoid granulomatosis--a condition with affinities to Wegener's granulomatosis and lymphoma

A case of lymphomatoid granulomatosis of the lung is described in which the presenting features were a skin eruption and peripheral neuropathy. The onset of the pulmonary symptoms of breathlessness and productive cough was delayed nine months but, when apparent, the extent of the radiological changes contrasted with the mildness of the symptoms and the triviality of the physical signs. Biopsy of the affected lung revealed a mixed lymphocytic, plasma cell, and histiocytic infiltrate following a perivascular distribution. This combination of clinical and pathological findings is in every detail that of lymphomatoid granulomatosis as recently identified by Liebow et al. (1972). Additional, previously undescribed, and unexplained findings in this case were persistent hypercalciuria and the presence in three axillary lymph nodes of subcapsular groups of cells resembling those of a benign naevus. This is the first case described in the British literature, and it is important that more cases be reported in order that the prevalence, prognosis, and aetiology of the condition should be further established.

Lymphomatoid granulomatosis: A clinicopathologic study of four cases

Four cases of lymphomatoid granulomatosis were studied. One case, previously reported, has had a prolonged remission of 8 years' duration. In one case, the course was rapid and progressive, and the patient died 2 months after the onset of the disease. In two other patients, the disease appears to be arrested effectively, both clinically and radiographically, by administration of corticosteroids. In the fatal case, postmortem examination revealed a typical angiocentric and destructive polymorphous lymphoreticular infiltrate in the lungs, kidneys, and adrenal glands. The diagnosis was made on specimens obtained from three patients by open thoracotomy. An adequate specimen is mandatory for diagnosis and thoractomy is indicated. To be considered in the differential diagnosis are Wegener's granulomatosis, the limited form of Wegener's granulomatosis, lymphoma, allergic granulomatosis, lymphocytic interstitial pneumonia, plasma cell granuloma, and infectious granuloma.