Neoplastic angioendotheliomatosis. Histologic, immunohistochemical, and ultrastructural findings in two cases

Episodic Visual Distortions and Stroke-Like Symptoms in a 56-Year-Old Man With Intravascular Lymphoma

A healthy 56-year-old man presented with vision changes and left upper extremity motor and sensory changes. MRI of the brain without contrast was significant for multifocal areas of restricted diffusion in multiple vascular territories. Neuro-Ophthalmic evaluation revealed an inferonasal visual field defect in the left eye, thickened choroid on optical coherence tomography, and bilateral delayed arteriovenous and choroidal filling on fluorescein angiogram. Repeat MRI demonstrated interval enlargement of many of the same foci of abnormal diffusion-weighted imaging signal. Computed tomography of the abdomen and pelvis revealed 3 distinct lobulated retroperitoneal masses that were biopsied and found to be consistent with diffuse large B-cell lymphoma. Brain biopsy specimens showed intravascular lymphocytes, confirming a diagnosis of intravascular lymphoma (IVL). In this diagnostically challenging case, a link was established between the presence of multiple strokes (some of which showed slow evolution over time) and retinochoroidal hypoperfusion, which provided a critical clue to the ultimate diagnosis of IVL.

A Small Case Series of Intravascular Large B-Cell Lymphoma with Unexpected Findings: Subset of Cases with Concomitant Extravascular Central Nervous System (CNS) Involvement Mimicking Primary CNS Lymphoma

Background

Intravascular large B-cell lymphoma (IVLBCL) is a rare type of extranodal lymphoma with growth mainly in the lumina of vessels. We studied a small series of IVLBCL and focused on its central nervous system (CNS) involvement.

Methods

Searching the medical records of Northwestern Memorial Hospital, we identified five cases of IVLBCL from January 2007 to January 2015. Clinical information, hematoxylin and eosin stained histologic slides and immunohistochemistry studies were reviewed for all cases. Polymerase chain reaction (PCR) analysis for the immunoglobulin (Ig) heavy and light chain gene rearrangement was performed on all five cases.

Results

Three of the five cases of IVLBCL were autopsies. Patients’ age ranged from 56 to 84. CNS involvement was present in two cases—in both patients, the CNS involvement showed an extravascular pattern with confluent sheet-like formation. PCR analysis confirmed that in one case the systemic intravascular and CNS extravascular components were clonally identical.

Conclusions

In a small case series of IVLBCL, we observed that CNS involvement by IVLBCL often has an extravascular morphology, but is clonally identical to the intravascular counterpart by PCR analysis. As IVLBCL can have a rapidly progressing poor outcome, it should be kept in the differential diagnoses for patients presenting with lymphoma of the CNS. The presence of extravascular growth patterns in the CNS should not exclude IVLBCL as a diagnosis.

Pulmonary Intravascular Large B-cell Lymphoma (IVLBCL) Disguised as an Asthma Exacerbation in a Patient with Asthma

A 62-year-old man with asthma presented with a 1-month history of wheezing and exertional dyspnea. Although the wheezing symptoms disappeared after systemic corticosteroid therapy, the exertional dyspnea and hypoxemia did not improve. A diagnosis of intravascular large B-cell lymphoma (IVLBCL) with pulmonary involvement was suspected because of the increased serum lactic dehydrogenase (LDH) and soluble interleukin-2 receptor (sIL-2R) level, increased alveolar-arterial oxygen difference (AaDO₂), decreased pulmonary diffusing capacity for carbon monoxide (D_LCO) and scintigraphic, computed tomography (CT) and ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography (PET)-CT findings. The patient was diagnosed as having IVLBCL with pulmonary involvement based on a pathological analysis of a random skin biopsy and a transbronchial lung biopsy. IVLBCL should be considered in patients with symptoms of asthma that are refractory to corticosteroid treatment.

Intravascular large B-cell lymphoma involving hemangiomas: an unusual presentation of a rare neoplasm

We report the clinicopathological features of two cases of intravascular large B-cell lymphoma involving cutaneous hemangiomas. The cases were identified from the consultation files of two of the authors. Both patients were women, 64 and 55 years of age, who presented with long-standing cutaneous hemangiomas of the posterior scalp and left shoulder, respectively. The lesions were brought to medical attention by an increase in size and change in color. Biopsies and immunohistochemical evaluation of the hemangiomas revealed extensive involvement by intravascular large B-cell lymphoma. The neoplastic cells were diffusely positive for CD20 in both cases and negative for CD3, pan-cytokeratin (AE1/AE3), epithelial membrane antigen, S-100, Factor VIII-related antigen, CD34 and CD31. Disease was limited to the hemangiomas in both patients. Treatment consisted of chemotherapy (both patients) and adjuvant radiation therapy (one patient). One patient had a recurrence of disease 33 months after initial diagnosis, leading to an autologous stem cell transplant. The other patient is without evidence of disease 27 months after initial diagnosis. Although this is a rare neoplasm, it is important to consider intravascular large B-cell lymphoma in the differential diagnosis of vascular lesions containing intravascular neoplastic cells.

Signs of rapidly progressive dementia in a case of intravascular lymphomatosis

Intravascular lymphomatosis (IVL), a rare type of non-Hodgkin's lymphoma, is an uncommon cause of progressive dementia, usually followed by death within a few months of onset of clinical disease. Often this aggressive tumor is only diagnosed at autopsy, because of misleading clinical features mimicking a broad spectrum of syndromes and the absence of circulating lympoma cells in the blood, bone marrow or cerebrospinal fluid in many cases. Here we present IVL in a 78-year-old woman with findings leading to the clinical diagnosis of vascular dementia with sudden beginning and positive 14-3-3 protein in the CSF, commonly reported in Creutzfeldt-Jakob disease (CJD).

Effects of crosslinking degree of an acellular biological tissue on its tissue regeneration pattern

It was reported that acellular biological tissues can provide a natural microenvironment for host cell migration and may be used as a scaffold for tissue regeneration. To reduce antigenicity, biological tissues have to be fixed with a crosslinking agent before implantation. As a tissue-engineering scaffold, it is speculated that the crosslinking degree of an acellular tissue may affect its tissue regeneration pattern. In the study, a cell extraction process was employed to remove the cellular components from bovine pericardia. The acellular tissues then were fixed with genipin at various known concentrations to obtain varying degrees of crosslinking. It was shown in the in vitro degradation study that after fixing with genipin, the resistance against enzymatic degradation of the acellular tissue increased significantly with increasing its crosslinking degree. In the in vivo subcutaneous study, it was found that cells (inflammatory cells, fibroblasts, endothelial cells, and red blood cells) were able to infiltrate into acellular tissues. Generally, the depth of cell infiltration into the acellular tissue decreased with increasing its crosslinking degree. Infiltration of inflammatory cells was accompanied by degradation of the acellular tissue. Due to early degradation, no tissue regeneration was observed within fresh (without crosslinking) and the 30%-degree-crosslinking acellular tissues. This is because the scaffolds provided by these two samples were already completely degraded before the infiltrated cells began to secrete their own extracellular matrix. In contrast, tissue regeneration (fibroblasts, neo-collagen fibrils, and neo-capillaries) was observed for the 60%- and 95%-degree-crosslinking acellular tissues by the histological examination, immunohistological staining, transmission electron microscopy, and denaturation temperature measurement. The 95%-degree-crosslinking acellular tissue was more resistant against enzymatic degradation than its 60%-degree-crosslinking counterpart. Consequently, tissue regeneration was limited in the outer layer of the 95%-degree-crosslinking acellular tissue throughout the entire course of the study (1-year postoperatively), while tissue regeneration was observed within the entire sample for the 60%-degree-crosslinking acellular tissue. In conclusion, the crosslinking degree determines the degradation rate of the acellular tissue and its tissue regeneration pattern.

Angiotrophic intravascular lymphosarcoma presenting as bi-cavity effusion in a dog

A 9-year-old German Shepherd cross was presented with a history of dyspnoea, decreased activity, episodic collapse and abdominal distention. Cytological examination of thoracic and abdominal fluid demonstrated neoplastic cells, either round or mesenchymal in nature. The dog was found to have a mass in the heart-base region. Exploratory thoracotomy was performed to identify the exact nature of the mass histologically, and to determine if it was the source of neoplastic cells seen in the effusions. Histological diagnosis of the mass was mesothelioma. Postoperatively the dog developed thrombocytopenia, probably immune-mediated, which was treated with prednisone therapy. The dog developed signs of respiratory distress shortly before discharge and, due to its deteriorating condition, was euthanased. A necropsy was performed and tissues were collected for histological examination. The histological diagnosis was angiotropic intravascular lymphosarcoma. Diagnosis of mesothelioma was not confirmed.

Multicolor karyotyping and clinicopathological analysis of three intravascular lymphoma cases

Intravascular lymphoma (IVL) is a rare neoplastic disease characterized by the presence of large malignant lymphoid cells in small vessels. It is often diagnosed at autopsy. Clinical manifestations are typically neurologic and dermatologic. Karyotypic abnormalities have been described in a small number of cases and have revealed complex alterations in the majority of cases. We have identified three cases of IVL with varied clinicopathological findings. Karyotypic analysis was undertaken by standard G-banding and supplemented by multi-colored karyotyping (M-FISH) to decipher the chromosomal content of marker chromosomes and undefined additions. M-FISH clarified the chromosomal abnormalities in two cases and unveiled cryptic translocations der(10)t(10;22), der(17)t(17;22), and balanced t(11;14). Comparison with previously published karyotypes revealed prominent involvement of chromosomes 1, 3, 6, 11, 14, and 18, similar to the pattern of clonal evolution in other B-cell lymphomas. The most frequent alterations seen were -6 or 6q- and +18 or dup(18q), with a minimally deleted region located at 6q21-q23 and a commonly amplified region located at 18q13-q23, respectively. Few differences between the classical and Asian variant of this disease were apparent at the karyotypic level. Cytogenetic analysis of additional cases supplemented by multicolor karyotyping may help identify the full spectrum of genetic alterations associated with IVL and assist in the delineation of the critical mutations associated with initiation and progression of this disease.

Angiolymphoid hyperplasia with eosinophilia: evidence for a T-cell lymphoproliferative origin

Angiolymphoid hyperplasia with eosinophilia (ALHE) is commonly regarded an angioproliferative process characterized by the presence of prominent, bizarrely shaped blood vessels. These vessels are accompanied by an inflammatory infiltrate that is thought to be a reactive component. Both the cell of origin and the pathogenesis of ALHE remain controversial. To define the histogenesis of this disorder, we analyzed the phenotypic and genotypic profile of the inflammatory infiltrate in ALHE by immunohistochemistry and T-cell receptor gene rearrangement by polymerase chain reaction (PCR) and denaturing gradient gel electrophoresis, as well as automated high-resolution PCR fragment analysis. Five of 7 ALHE patients displayed a clonal T-cell population and proliferative T-cell activity in lesional tissue. Most of these cases followed a protracted and therapy-reluctant course with recurrences. These data suggest that ALHE or a subset of ALHE cases harboring a clonal T-cell population may represent a T-cell lymphoproliferative disorder of a benign or low-grade malignant nature.

Intravascular lymphoma presenting as symmetric polyarthritis

Intravascular lymphoma (IVL) is an uncommon neoplastic disorder characterized by monoclonal intravascular expansion of lymphoid cells. Occlusion of small vessels in various organ systems probably accounts for the broad clinical spectrum of this type of lymphoma, which can closely mimic a variety of diseases, especially vasculitic disorders, and thus lead to delayed clinical diagnosis. This is the first report of a patient who presented with a predominant symptom of symmetric polyarthritis accompanied by fever. While her initial systemic symptoms, such as fever, improved rapidly after initiation of corticosteroid therapy, the response of the polyarthritic joint manifestations was only transient. The patient died of progressive lung involvement and was diagnosed as having IVL by histologic analysis of tissue samples obtained postmortem.

Cutaneous vascular proliferations. Part III. Malignant neoplasms, other cutaneous neoplasms with significant vascular component, and disorders erroneously considered as vascular neoplasms

In this third and last part of our review of cutaneous vascular proliferations we include malignant vascular neoplasms and a group of heterogeneous cutaneous neoplasms characterized by a significant vascular component. We also review some disorders that, in our opinion, have been erroneously considered as vascular neoplasms. We review the epidemiologic, histogenetic, clinical, and histopathologic aspects of Kaposi's sarcoma in its four distinctive variants (classic, African-endemic, immunosuppressive drug-associated, and AIDS-associated Kaposi's sarcoma). There is still controversy about whether Kaposi's sarcoma represents a reactive vascular proliferation or a true neoplastic proliferation. In any event, most authors believe that Kaposi's sarcoma does not produce metastatic disease, but rather develops in multifocal fashion. However, Kaposi's sarcoma may cause death, especially in immunosuppressed patients. Epithelioid hemangioendothelioma, Dabska's tumor, and retiform hemangioendothelioma are examples of low-grade angiosarcoma. In contrast, cutaneous angiosarcomas, including the clinical variants of angiosarcoma of face and scalp in elderly patients, angiosarcoma associated with lymphedema, and radiation-induced angiosarcoma are highly aggressive neoplasms with poor prognosis and most patients die within a short period after presentation. A group of benign and relatively frequent cutaneous neoplasms, including multinucleate cell angiohistiocytoma, angiofibroma, angioleiomyoma, angiolipoma, cutaneous angiolipoleiomyoma, and cutaneous angiomyxoma are here covered because of their significant vascular component. Finally, we review briefly a series of cutaneous disorders that have been erroneously considered as vascular neoplasms. Kimura's disease is an inflammatory reactive condition of unknown origin, "benign" angioendotheliomatosis is a reactive intravascular proliferation of endothelial cells that occurs in the skin as a response to a variety of stimuli, "malignant" angioendotheliomatosis is an intravascular lymphoma, and acral pseudolymphomatous angiokeratoma of children (APACHE) is better interpreted as a pseudolymphoma.

Intravascular lymphomatosis presenting as adult respiratory distress syndrome

An unusual case of intravascular lymphomatosis caused by small noncleaved, non-Burkitt's lymphoma, which presented with adult respiratory distress syndrome, is described. Extensive invasion of the small- and medium-size blood vessels of the lung, liver, spleen, kidneys, heart, esophagus, stomach, small and large intestines, bladder, and brain-but not the bone marrow or peripheral blood-is documented. The possible mechanism and the unusual features of this case are discussed in comparison with previously reported cases. The pertinent literature is reviewed. The problem of diagnosing this pathological entity is emphasized.

Intravascular large cell lymphoma coexisting within hemangiomas of the skin

Intravascular lymphomatosis is a rare and peculiar subtype of large cell lymphoma. The authors present the pathologic, clinical, and radiologic findings of a patient with intravascular large cell lymphoma coexisting within hemangiomas of the skin. Initially the lymphoma was clinically confined to the hemangiomas and the patient was closely observed for disease progression. Within 10 months the patient developed disseminated lymphoma involving both adrenals. A clinical remission was achieved, but the patient soon relapsed, and despite further chemotherapy he died with disseminated disease 23 months after the initial diagnosis. This report presents the only known case of an intravascular large cell lymphoma coexisting within a vascular lesion and highlights the potential aggressive nature of intravascular lymphomas.

Angiotropic large cell lymphoma presenting as primary adrenal insufficiency

Angiotropic large cell lymphoma is reported in two patients who developed severe metabolic acidosis and unexplained hypotension before death. In addition to the usual multiorgan involvement of the disease, the adrenal glands of both patients were symmetrically enlarged. Histologically, the cortical vessels were engorged and filled with neoplastic lymphoid cells of B-cell lineage, whereas the parenchymal cells were compressed and atrophic. Angiotrophic large cell lymphoma seems to be a distinct and unrecognized cause of primary adrenal insufficiency, and should be included in the differential diagnosis of adrenal hormone deficiency.

Angiotropic large cell lymphoma: simultaneous peripheral nerve and skeletal muscle involvement

Angiotropic large cell lymphoma is a rarely encountered disorder characterized by a proliferation of malignant lymphoid cells within vascular lumina. Sites usually affected include the skin and central nervous system, although involvement of multiple other organ symptoms have been described including peripheral nerve and skeletal muscle. Simultaneous involvement of both skeletal muscle and peripheral nerve has rarely been reported. In most of those cases the diagnosis was made only at the time of autopsy. A case of an elderly male with angiotropic large cell lymphoma and in whom the diagnosis was made antemortem on a peripheral nerve and skeletal muscle biopsy is reported.

Neurologic manifestations of intravascular lymphomatosis

Intravascular lymphomatosis is a rare fatal neoplasm characterized by malignant cells of lymphocytic lineage producing vascular occlusions. The cerebral vasculature is particularly affected. Two patients seen at our institution presented with progressive neurologic deficits including dementia, hemiparesis and myelopathy. Review of an additional 64 reported cases with neurologic involvement indicates that patients developed intermittent fevers, an encephalopathy ranging from acute disorientation to rapidly progressive dementia, and focal signs such as hemiparesis and myelopathy. Common laboratory abnormalities include elevated cerebrospinal fluid protein and a lymphocytic pleocytosis, elevated blood erythrocyte sedimentation rate and serum lactate dehydrogenase. Malignant cells are rarely seen in cerebrospinal fluid, blood or bone marrow. Neuroimaging is usually abnormal with parenchymal lesions seen on cerebral tomography and magnetic resonance imaging along with an occasional meningeal pattern of contrast enhancement. Treatment with corticosteroids, chemotherapy, radiation therapy, or plasmapheresis provided limited benefit. Intravascular lymphomatosis should be considered in the differential diagnosis of unexplained progressive encephalopathy with superimposed focal deficits.

Four varied cases of intravascular lymphomatosis and a literature review

BACKGROUND

Intravascular lymphoma (IVL) is an uncommon malignancy defined pathologically by neoplastic proliferation of lymphoid cells within the lumens of capillaries, small veins, and arteries, with little or no adjacent parenchymal involvement. The nature of IVL has been the subject of considerable controversy. Recent immunohistochemical studies have demonstrated clearly that the tumors bear the immunophenotype of neoplastic lymphoid cells of either B-cell or T-cell lineage. IVL commonly affects the central nervous system, resulting in progressive dementia and multiple neurologic deficits; skin is the second most common site of involvement, in the form of cutaneous plaques and nodules.

METHODS

In a retrospective review of all cases of non-Hodgkin's lymphoma seen at our institution, four cases of IVL were identified. Case 1 was fixed in methacarin, and Cases 2-4 were fixed in 10% formalin. Standard fixation, tissue processing, sectioning, and hematoxylin and eosin staining were used. Immunophenotypic studies were performed using a modified avidin-biotin complex technique. The specimen in Case 1 was stained by Giemsa stain using standard techniques.

RESULTS

Four cases of IVL are presented. One patient experienced hypoxemia and fevers of unknown origin; the second, dementia and a vasculitislike illness; the third rapidly progressive dementia, nonlocalizing neurologic deficits, and panhypopituitarism; the fourth Kaposi-like skin lesions. Case 1 relapsed shortly after completing chemotherapy. Salvage chemotherapy has yielded good initial response. Autopsy findings in cases 2, 3 and 4 confirmed IVL in many vessels, including the brain, lung, liver, heart, gastrointestinal tract, glomerulus, central nervous system, and skin. Malignant lymphoid cells marked as B-cells in all cases.

CONCLUSIONS

Unusual and interesting clinical presentations may occur in patients with IVL. The medical literature indicates that few cases are diagnosed ante mortem. Although isolated patients may respond favorably to chemotherapy, most will deteriorate rapidly and the diagnosis of IVL not contemplated until necropsy.

Angiotropic intravascular large-cell lymphoma with massive cerebral extension

Angiotropic intravascular large-cell lymphoma (AILL) is a rare, generally fatal disease characterised by a multifocal proliferation of neoplastic mononuclear cells within small blood vessels. The diagnosis of a patient was made at necropsy. The malignant cells had infiltrated the periventricular areas of the brain.

Uveal involvement in systemic angiotropic large cell lymphoma. Microscopic and immunohistochemical studies

BACKGROUND

Angiotropic large cell lymphoma is a rare, generally fatal disease characterized by multifocal proliferation of neoplastic mononuclear cells within the lumens of blood vessels.

METHODS

The authors report the clinical and immunohistochemical features of four patients with angiotropic large cell lymphoma.

RESULTS

All patients presented with central nervous system symptoms, and three of the four had fever of unknown origin and anemia. The diagnosis was established by postmortem examination of the eyes in four patients and additionally by autopsy in three of the four patients. Two of the three autopsied patients had rare foci of extravascular involvement. One patient had erythrophagocytosis. Immunohistochemical stains on paraffin-embedded sections confirmed the diagnosis of lymphoma in all four patients.

CONCLUSION

The results of this study support the B-cell lymphocyte origin of angiotropic large cell lymphoma.

Intravascular lymphomatosis. A systemic disease with neurologic manifestations

BACKGROUND

Intravascular lymphomatosis (IL) is a systemic neoplasm that often involves the nervous system, inducing progressive neurologic deficits in the setting of undiagnosed or quiescent extranodal non-Hodgkin lymphoma.

METHODS

The clinical and pathologic files of the Massachusetts General Hospital and New York University Medical Center and the English language literature were reviewed to identify all reports of intravascular lymphomatosis (angioendotheliomatosis) or other examples of a diffuse proliferation of neoplastic cells filling capillaries, arterioles, and venules.

RESULTS

The authors report seven patients with IL and note 114 patients reported in the literature. Almost two-thirds (63%) of patients had neurologic manifestations, without abnormalities on bone marrow biopsy, chest and abdominal tomographic examinations for adenopathy, and cerebrospinal fluid (CSF) analysis. All patients had one or more of four syndromes, each reflecting a vascular occlusive process: progressive, multifocal cerebrovascular events; paraparesis, pain, and incontinence; a subacute encephalopathy; and peripheral or cranial neuropathies.

CONCLUSIONS

The unexplained presence of any one or more of these neurologic syndromes should alert the physician to the possible presence of this disease.

Angiotropic lymphoma (intravascular large cell lymphoma) presenting with cauda equina syndrome

A 50-year-old man developed cauda equina syndrome of unknown etiology that was stable for 20 months. Two months prior to sudden death, he experienced new back pain, confusion, seizures, and multiple cranial nerve palsies. Neuropathologic examination revealed angiotropic lymphoma without parenchymal involvement or infarcts in the brain, spinal cord, and muscle. In addition, nerve roots in the cauda equina contained angiotropic lymphoma and infarcts of various ages. Angiotropic lymphoma should be considered as a cause of cauda equina syndrome and of disorders that affect the central and peripheral nervous systems concurrently.

Primary large cell lymphoma of the splenic sinuses: a variant of angiotropic B-cell lymphoma (neoplastic angioendotheliomatosis)?

A case of large cell lymphoma of B-cell lineage originating in the splenic sinuses is described. In addition to widening the spectrum of primary malignant lymphomas of the spleen, this case raises the possibility that variants of angiotropic large cell lymphomas may exist that do not involve blood vessels but do involve the spleen and lymph node sinuses.

Non-Hodgkin's lymphoma with histological features of neoplastic angioendotheliosis

Three cases of non-Hodgkin's lymphoma, B-cell type, identical histologically to so-called neoplastic angioendotheliosis (NAE), are reported. All showed a rapidly progressive clinical course and were not properly diagnosed before death. The lymphoma cells were distributed in many vessels of systemic organs with a tendency to form aggregates. The primary sites in the three cases were probably the adrenal gland, lymph node, and spleen, respectively. In particular, in one case it was suggested that the lymphoma cells had spread from the adrenal tumor to other organs, showing the histological features of NAE. In the literature, the primary sites of NAE have been scarcely mentioned. However, gross tumors were present in some cases. In such cases, it is possible that the tumors could be the primary sites of NAE. We conclude that some non-Hodgkin's lymphomas can exhibit the features of NAE during their course, particularly in the terminal stages.

Malignant proliferative angioendotheliomatosis or angiotropic lymphoma associated with a soft-tissue lymphoma

We report a 63-year-old man with violaceous nummular patches on the trunk. Histopathologic studies were consistent with a diagnosis of malignant angioendotheliomatosis or angiotropic lymphoma. Immunohistochemical study of skin was positive for UCHL-1 antigen and leukocyte common antigen and negative for L-26, Ulex europaeus lectin I, vimentin, cytokeratin, and epithelial membrane antigen. Ultrastructural study ruled out an endothelial origin of the neoplastic cells. These data confirmed the diagnosis of malignant proliferative angioendotheliomatosis. Five years before, a soft tissue lymphoma had been excised. This is an unusual case of malignant angioendotheliomatosis for the following two reasons: (1) a previous association with a soft tissue lymphoma and (2) the rarely described T immunophenotype of neoplastic lymphoid cells.

Angiotropic lymphoma (malignant angioendotheliomatosis) presenting with rapidly progressive dementia

An 87-year-old male presented with rapidly progressive dementia, disorder of consciousness and myoclonus, suggesting Creutzfeldt-Jakob disease, but with nonspecific EEG and negative CT findings. Autopsy revealed a malignant angiotropic lymphoma with accumulation of tumor cells within small vessels of the brain and visceral organs. Immunohistochemistry disclosed a large cell lymphoma of B cell type.

Intravascular lymphomatosis (neoplastic angioendotheliosis) of the central nervous system: case report and literature review

A 63-year-old woman developed gradual slowness, recurrent multifocal deficits, severe constitutional symptoms and hypopituitarism which progressed to death over 2.5 months. Elevation in lactico dehydrogenases was the main biological abnormality. Necropsy showed an intravascular malignant proliferation which proved to be a lymphoma of B-lineage. In order to better define diagnostic criteria, we reviewed previously reported cases of intravascular lymphomatosis of the central nervous system. A strategy for establishing the diagnosis is proposed.

Immunocytochemical evidence of lymphocytic derivation of neoplastic cells in malignant angioendotheliomatosis

Neoplastic angioendotheliomatosis is a rare disorder usually characterized by primarily cutaneous or neurological symptoms. Approximately 40 cases of malignant angioendotheliomatosis with primary central nervous system (CNS) symptoms have been reported. Some investigators have postulated a hematopoietic origin for this neoplasm. Most of the literature, however, has perpetuated the idea that the often bizarre symptoms seen with this entity result from neoplastic endothelial cell proliferation within the small vessels of affected organs, including the brain and spinal cord. This report describes the immunohistochemical examination and confirmation of the cell of origin of this neoplasm based on five previously unpublished cases of malignant angioendotheliomatosis with primarily CNS symptoms. It includes the first documentation of a T-cell lymphoma presenting as malignant angioendotheliomatosis. All cases include autopsy findings, and in four cases the diagnosis was made postmortem. One case was proven by stereotactic biopsy, but the patient succumbed as a result of severe intracranial bleeding that occurred at the time of biopsy. Tissues were studied with avidin-biotin peroxidase immunohistochemical techniques using a panel of monoclonal antibodies directed against the leukocyte common antigen, LN-1, LN-2, and anti-Factor VIII, and also using Ulex europaeus agglutinin 1. Based on the results obtained, the authors conclude that the proliferative cells seen within the vessel lumina are of lymphocytic origin and agree that the condition should more properly be designated intravascular lymphomatosis. The therapeutic implications of this conclusion point to the possible administration of chemotherapy and radiotherapy in an effort to achieve remissions in an otherwise relentlessly progressive neurological disorder.

Cerebral angiotropic large cell lymphoma (neoplastic angioendotheliosis): therapeutic considerations

Cerebral angiotropic large cell lymphoma (neoplastic angioendotheliosis) is a rare disease with a particular propensity to affect the central nervous system by vascular occlusion. Because the disease is rare and there are no specific diagnostic procedures apart from cerebral biopsy, it is difficult to diagnose in life. Accordingly, chemotherapy or radiotherapy has only rarely been attempted and their effectiveness is uncertain. We established the diagnosis in a 62-year-old patient by cerebral biopsy and observed remission following institution of combination chemotherapy. Unfortunately, neurologic deterioration recurred during maintenance chemotherapy. We identified 30 patients in the literature who initially presented with definite central nervous system manifestations and whose clinical conditions were described sufficiently enough for comparison with our case. Eleven patients had the diagnosis made in life, but only 5 received chemotherapy other than corticosteroid hormones. Our patient's survival for 16 months exceeded that in the majority of the 30 reported cases. Intense anti-lymphoma chemotherapy, and possibly radiotherapy, may be beneficial and should be studied in this otherwise rapidly fatal disease. It seems certain that early diagnosis is essential if therapeutic intervention is to be successful.

Immunohistochemical evaluation of vascular neoplasms

Immunohistochemistry is of proven value in the evaluation of cutaneous vascular neoplasms. Nonetheless, the lack of sensitivity and specificity demonstrated by some endothelial markers requires that a panel of antibodies to other lineage-related determinants be applied in this context. Compared with electron microscopy, enzyme-linked antibody techniques can be applied in a cost-effective manner, with a satisfactory diagnostic result in most cases. The efficacy of these methods will likely improve as more sensitive and specific markers of endothelial differentiation are characterized. For the time being, the exclusion of non-endothelial proliferations remains an important aspect of the differential diagnosis of vascular tumors.

Angiotropic intravascular large-cell lymphoma (malignant angioendotheliomatosis): report of a case and review of the literature

We present a case of angiotropic large-cell lymphoma and review the literature in order to define the neurologic features of this rare disorder. This is the first report of gadolinium-DTPA imaging in angiotropic large-cell lymphoma that demonstrates infarcts of multiple ages, as well as striking meningeal enhancement. Angiotropic large-cell lymphoma should be suspected in patients with clinical evidence of small and large cerebral vessel disease and diagnosis requires skin, liver, renal, meningeal, or brain biopsy. Single modality treatment, using either radiation therapy or steroids, has been ineffective, and new findings of a lymphomatous origin of this neoplasm suggest that combination chemotherapy may be indicated.

Pulmonary malignant angioendotheliomatosis. Presentation with fever and syndrome of inappropriate antidiuretic hormone

A 64-year-old man presented with protracted fever, hyponatremia, and mononeuritis multiplex. Inappropriate antidiuretic hormone secretion was established. The absence of pulmonary infiltrates precluded any lung biopsy. Autopsy revealed malignant angioendotheliomatosis involving multiple organs including the alveolar septa and pulmonary vasculature. An early diagnosis of MAE in the setting of fever and SIADH may be possible via transbronchial biopsy.

Angiotropic (intravascular) large cell lymphoma. A clinicopathologic study of seven cases with unique clinical presentations

The authors recently reported the antigenic phenotypes of three cases of so-called "malignant angioendotheliomatosis" and suggested that angiotropic large cell lymphoma (ALCL) is a more appropriate designation for this disease. The authors now report an additional seven cases of ALCL with unique clinical presentations. One patient presented with prostate enlargement, the second with lytic bone lesions and thickened nasal sinus mucosa, the third had diffuse myalgia, the fourth had dyspnea and pulmonary infiltrates, the fifth had gangrene of the lower extremities, total-body skin involvement, and pancytopenia, the sixth had a lesion of the foreskin mimicking squamous cell carcinoma, and the seventh had a mediastinal mass. In all cases histologic features were characteristic of ALCL with, in two cases, extravascular spread into soft tissue. Immunohistologic studies showed a B-cell phenotype in five cases and a T-cell phenotype in one case. Two patients received combination chemotherapy using established treatment protocol for large cell lymphoma, and remain in complete clinical remission and two patients are responding clinically to combination chemotherapy. Two patients died shortly after receiving combination chemotherapy. One patient has only recently been diagnosed as having ALCL and no long-term follow-up is available. These data indicate that, although ALCL affects predominantly the central nervous system and skin, unusual clinical presentations may occur, and patients with ALCL may respond to combination chemotherapy for large cell lymphoma.

"Intravascular lymphomatosis" (angioendotheliomatosis): evidence for a T-cell origin in two cases

Intravascular lymphomatosis (IL) is a rare and potentially fatal multifocal intravascular proliferative disorder, most often involving the skin and the central nervous system. Originally considered an endothelial disorder, IL has recently been reclassified as an angiotropic lymphoma, most often of B-cell origin. We report immunocytochemical and ultrastructural findings in two patients with IL, both representing angiotropic T-cell lymphomas. In one patient, lesional tissue was examined by Southern blot analysis and monoclonal T-cell receptor rearrangement was found. As an additional feature in one patient, a myelosuppressive serum factor was demonstrated in peripheral blood progenitor cell cultures as the cause of underlying chronic anemia and leukopenia; this factor is thought to be a cytokine product of the lymphoma cells.

Immunohistochemical and cytogenetic studies indicate that malignant angioendotheliomatosis is a primary intravascular (angiotropic) lymphoma

The authors performed immunohistochemical and cytogenetic studies in a 73-year old man with malignant angioendotheliomatosis. The patient was referred for evaluation of fever of unknown origin, hepatic failure, and neurologic deterioration. Examination of a muscle biopsy revealed numerous, noncohesive atypical mononuclear cells within small vessels. These cells stained positively with a pan-leukocyte marker CD45(PD7/26/16) and with a B-cell marker L26 but negatively with Factor VIII-related antigen, an endothelial cell marker. Peripheral blood obtained before chemotherapy was cultured and analyzed by the G-band method. A new translocation and numerous chromosomal aberrations were identified. The major cell line karyotype was 53,XY, +X, +5q?,-6, +i(6p), +7, -10, +11, -12, +12p-, +12p-, +18, +mar1, +mar2, t(1;3)(p22;p21),3q+,8p+. This is the first cytogenetic study performed in a case of malignant angioendotheliomatosis. Our findings demonstrate that the neoplastic cells in this disorder circulate in the peripheral blood and provide further evidence that malignant angioendotheliomatosis is a diffuse intravascular neoplasm of lymphoid origin. Furthermore, the authors conclude that this malignant lymphoproliferative disorder should be reclassified as a primary intravascular (angiotropic) lymphoma.

Malignant angioendotheliomatosis (Angiotropic lymphoma) of the gallbladder

We present a case of malignant angioendotheliomatosis of the gallbladder, the first reported. Diagnostic problems connected with this rare malignancy are underlined. Immunohistochemical studies were useful in providing further evidence of the lymphoid nature of the neoplasm and avoiding possible misdiagnosis. We suggest that the term "angiotropic lymphoma" might be more appropriate to define this malignancy.

Intravascular lymphomatosis presenting in the lung

We report four patients who had intravascular lymphomatosis (IVL) that presented as interstitial lung disease. All four patients had progressive shortness of breath, weight loss, fever, and diffuse interstitial infiltrates on chest radiographs. Open lung biopsy samples showed an interstitial pneumonia except for the intravascular proliferation of large lymphoid cells associated with irregular congestion, fibrin microthrombi, and intimal proliferation in vessels. This appearance corresponded to an intravascular large cell lymphoma (malignant angioendotheliomatosis [MAE], angiotropic lymphoma). The differential diagnosis of IVL with other pulmonary lymphoproliferations and intravascular malignancies is reported.

Malignant angioendotheliomatosis: an angiotropic lymphoma

Malignant angioendotheliomatosis is a rare, systemic, usually fatal disease characterized by massive proliferation of large, neoplastic, mononuclear cells within the lumen of small blood vessels. Recent studies suggested that the tumor cells are of lymphoid origin. We studied two cases of malignant angioendotheliomatosis by Southern blot hybridization analysis that showed rearrangements of the immunoglobulin heavy chain and kappa light chain (case 2), indicating the presence of a monoclonal B cell lymphoma. Our results provide further evidence that malignant angioendotheliomatosis is an angiotropic lymphoma.

Phenotypic comparison between mesothelial and microvascular endothelial cell lineages using conventional endothelial cell markers, cytoskeletal protein markers and in vitro assays of angiogenic potential

Endothelial and mesothelial cells are mesodermally derived simple squamous epithelial cells. A controversy concerning the ontogenetic origin of neoplasms derived from these cell types, commonly cited in the literature, is whether Kaposi's sarcoma is a mesothelioma or an angioma. To assess the similarities and differences between these cell types, pulmonary microvascular endothelial cells (PMVEC) and pericardial mesothelial cells (PMC) were cultured in vitro. PMVEC and PMC were found to be difficult to distinguish from one another by histological criteria alone. Both cell types formed contact-inhibited, and 'cobblestone', monolayers typical of simple epithelial cells. PMVEC and PMC demonstrated positive immunoreactivity to Factor VIII-related antigen and angiotensin-converting enzyme (ACE) antigen. They also showed uptake of 1,1'-dioctacecyl-1,3,3,3',3-tetramethyl-indocarbocyanine perchlorate acetylated low density lipoprotein (DiI-Ac-LDL) in 4 h. Both PMVEC and PMC expressed low ACE activities when compared to macrovessel endothelial cells. PMVEC and PMC shared similar isoform profiles for vimentin and actin. Both cell types expressed the simple epithelial keratins, cytokeratins 8 and 19, though PMC contained 50% more cytokeratins than PMVEC. Additionally, PMC contained cytokeratin 18, an intermediate filament protein not detectable in PMVEC. PMC formed 15 times as many epithelial ringlets or "stomata" as PMVEC. PMVEC but not PMC could be induced in vitro to differentiate into branching tube-like structures in response to their culture environment. Reorganization of PMVEC into vessel-like structures was more rapid and complete than PMC when embedded in three-dimensional collagen I lattices, cultured on Matrigel or exposed to a shaped-pulsed electromagnetic field. The angiogenic response of PMVEC to specialized culture conditions in vitro may reflect their phenotypic differentiation state characterized by anastomosing vascular structures in vivo, whereas PMC remain differentiated into monolayer sheet-like structures.

Angiotropic large cell lymphoma (intravascular malignant lymphomatosis) of the kidney: presentation as minimal change disease

We report the first case of angiotropic large-cell lymphoma (intravascular malignant lymphomatosis) presenting as minimal change disease (MCD) and diagnosed by renal biopsy. Neoplastic lymphoid cells were disseminated throughout the glomerular capillary bed and were associated with diffuse foot process effacement. The tumor had the immunophenotype of a B cell lymphoma (reactive with LCA and L-26 and unreactive with FVIII-R-Ag, Leu-M-1, alpha-1-antichymotrypsin, lysozyme, UCHL-1, Leu-22, kappa, and lambda). The temporal association between the onset of lymphoma and MCD, and the failure of the nephrotic syndrome to respond to immunosuppressive therapy support a role for lymphoma in the pathogenesis of MCD in this patient.

Acute mononeuropathy with angiotropic lymphoma

Angiotropic lymphoma can present as a vascular disease in the central nervous system. The patient described in this report had a sudden pain in the region of the right superficial peroneal nerve and a nerve biopsy showed tumoral cells in the lumen of most small blood vessels. This pathology, first described in the skin as malignant angioendotheliomatosis, can be compared with the occurrence of multiple emboli in the vasa nervorum. In recent cases, tumoral markers have evidenced a lymphomatous origin, generally of the B type.

Factor VIII-related antigen in canine endothelial neoplasms: an immunohistochemical study

Canine vascular tumors (47 hemangiomas, 36 hemangiosarcomas) were investigated for the endothelial cell marker factor VIII-related antigen (F VIII RAg). The primary antibody was a commercial rabbit anti-human (r/h) F VIII RAg antiserum. All (100%) hemangiomas and 32 (89%) of 36 hemangiosarcomas stained for F VIII RAg. One hemangiosarcoma (3%) was negative, and three tumors (8%) were equivocal in staining. Rarely, the interpretation of stained immature endothelial cells was difficult. The r/h F VIII RAg antibody was a positive marker of normal, reactive, and neoplastic endothelial cells in the dog.