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

Angiocentric T-cell lymphoma presenting as midface destructive lesion: case report and literature review

A case of angiocentric T-cell lymphoma presenting as a midface destructive lesion is reported. Angiocentric T-cell lymphoma typically manifests as an aggressive, progressively destructive, and necrotizing disorder, often with a fatal outcome. This case was characterized microscopically by the presence of an atypical lymphoid population that expressed a CD45+, CD3+ cytoplasmic, CD5+, and CD56- T-cell phenotype within a background of a polymorphous inflammatory infiltrate. Because of the rarity of the disorder, the differential diagnosis is discussed. Recent advances in clinical immunodiagnostics, the variations in therapeutic modalities, and the prognosis of the disease as reported in the recent literature are reviewed.

Polymorphic reticulosis is a neoplasm of large granular lymphocytes with CD3+ phenotype

BACKGROUND

Polymorphic reticulosis, a type of lethal midline granuloma (LMG), has been referred to as nasal T-cell lymphoma (NTL) because of its proliferating cells' positive reactivity to anti-T-lymphocyte antibodies. Recently, several studies have suggested that proliferating cells in NTL may be natural killer (NK) in nature. NK cells and human nonmajor histocompatibility-restricted cytotoxic T-lymphocytes have the morphology of large granular lymphocytes (LGL) (i.e., a high cytoplasmic:nuclear ratio and cytoplasmic granules). Whether NTL-LMG possesses an LGL morphology is examined in this study.

METHODS

Two lymph node smears, peripheral blood showing a leukemic picture, and an electron microscope (EM) examination of a cutaneous lesion, respectively, were obtained from four patients with NTL-LMG. Immunohistochemical examination of the proliferating cells and of the Epstein-Barr virus (EBV) genome by both polymerase chain reaction and in situ hybridization also were performed.

RESULTS

All patients presented with necrotic and granulomatous lesions in the upper respiratory tract. Histology showed polymorphous cellular infiltrates containing large atypical cells with positive reaction to CD3 (three patients), CD43 (two patients), CD45RO (two patients), and OPD4 (one patient). Imprint smears revealed azurophilic large membrane-delimited granules in an ample cytoplasm, which was confirmed by EM. The presence of the EBV genome in the tumor cells was observed in one patient.

CONCLUSION

The current findings showed that NTL-LMG or polymorphic reticulosis is a proliferation of LGL with a CD3+ phenotype.

Midline malignant B-cell lymphoma with leukemic transformation

This article presents a case of lethal midline granuloma on the palate of a 44-year-old woman, which had been identified histologically as B-cell lymphoma with leukemic transformation in the terminal stages. At the first visit, physical and laboratory examinations showed no remarkable findings except for a necrotizing ulcer of the palate, and the biopsy specimens only showed massive inflammatory cell infiltration and necrosis of the granulation tissue. There was a short-term resolution after treatment with cyclophosphamide and prednisolone, but the disease reactivated and the necrotic ulcerative lesion progressively advanced into the nasal cavity. Specimens from the third biopsy exhibited histologic features that were consistent with malignant lymphoma of the diffuse, mixed B-cell type. Chemotherapy with the regimen of cyclophosphamide, doxorubicin, vincristine, and prednisolone was adopted but was interrupted after a short time because of bone marrow suppression. Subsequently, large numbers of enlarged abnormal lymphocytes with a few vacuoles in the cytoplasm appeared in the circulating blood, indicating leukemic transformation of the midline lymphoma. The patient died on the seventh day after the initiation of chemotherapy. In the presentation of this case, the authors mention clinically important matters regarding midline lethal lymphoma and briefly discuss the pathophysiology and pathogenesis.

A clinicopathologic study of malignant lymphomas of the nose, paranasal sinuses, and hard palate, including cases of lethal midline granuloma

Malignant lymphomas of the nose, paranasal sinuses, and hard palate show marked clinicopathologic, immunologic, and prognostic diversity. The clinical features and pathologic spectrum of these lesions were studied in 20 cases (11 female and 9 male cases) with a mean age of 51 years at initial presentation. Malignant lymphomas of the large cell type were most frequently encountered (11/20). The next largest category was malignant lymphoma, diffuse, mixed small and large cell type (six of 20). Two thirds, 13 of 20 cases, had morphologic features suggestive of peripheral T-cell lymphomas. Necrosis, an angiocentric growth pattern, and epitheliotropism were found in nine, eight, and three cases, respectively. Of ten cases immunophenotyped on fresh-frozen or fixed, paraffin-embedded tissue sections, eight had a T-cell phenotype and two had a B-cell phenotype. Of 17 patients with sufficient follow-up data, ten are alive (median follow-up 33 months) and seven are dead (median survival 12 months). Patients with clinical Stages IE and IIE did not have a superior 5-year survival to those with more advanced disease. Histologic type also did not correlate with survival but this may be due to the aggressive histologic grade of the majority of cases and the retrospective nature of this study. The authors conclude that, despite the overall high-grade histologic type, the pathologic spectrum of malignant lymphomas involving this anatomic region is broad. Furthermore, some cases do not fit well into the National Cancer Institute (NCI) Working Formulation but more closely resemble the histologic features of peripheral T-cell lymphomas described in Japan.

An autopsy case of so-called midline malignant reticulosis followed by extensive dissemination with immunohistochemical evidence for its T cell malignancy

An autopsy case of malignant midline reticulosis (MMR) is reported. The patient, a 42-year-old Japanese male, died after a clinical course of 22 months. Autopsy revealed extensive infiltration of generalized organs by the tumor cells, suggesting that the disease was highly malignant in nature. Staining with monoclonal antibodies against T-cell surface antigens Leu 4 on frozen sections and UCHL1 on paraffin-embedded sections enabled us to examine the phenotype of the tumor cells with good morphological preservation and to verify the T cell nature of the tumor.

Current concepts of the lethal midline granuloma syndrome

"Lethal midline granuloma" is an unusual but devastating spectrum of lymphoproliferative disorders that is now thought to include four entities: idiopathic midline destructive disease, Wegener's granulomatosis, polymorphic reticulosis, and nasal lymphoma. These disorders must be considered in the differential diagnosis of any patient with chronic, nonspecific complaints localized to the upper airway. An aggressive diagnostic and therapeutic approach may significantly decrease morbidity and death resulting from these lesions.

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.

Malignant lymphoma of the oral cavity: clinicopathologic analysis of 20 cases

Twenty cases of malignant lymphomas (ML) of the oral cavity were reviewed in the light of recent histologic classification. They occurred in 12 male and 8 female patients, with the age range of 11-80 years (median 51 years of age). Eighty percent of patients were stages IE and IIE. Histologically, 15 cases (75%) were ordinary non-Hodgkin's lymphoma (NHL) with diffuse large cell type being the most common. The remaining 5 cases, undefinable by classification scheme for ordinary NHL, were designated as malignant histiocytosis of the oral cavity (3 cases) and peripheral T-cell lymphoma (2 cases), respectively. There were no cases of follicular lymphoma. The present cases comprised 45% of high grade, 40% of intermediate grade, and 15% of low grade malignancy. A follow-up study showed that the stage of diseage, histologic classification, and frequency of mitosis correlated well with survival.