Angioimmunoblastic lymphadenopathy: clinical, biologic, and follow-up study of 14 cases

Clinicopathologic and therapeutic aspects of angioimmunoblastic lymphadenopathy-related lesions

The clinicopathologic features of 14 patients with angioimmunoblastic lymphadenopathy (AIL)-related lesions were analyzed. Lymph node biopsy specimens from all the patients showed a diffuse obliteration of lymph node architecture, prominent vascular proliferation, a polymorphous cellular infiltrate, including immunoblasts, and varying degrees of clear cell proliferation. The patients were eight males and six females, with a median age of 58.5 years. All but one were in an advanced stage at the time of diagnosis. Bone marrow involvement was observed in eight patients. Thirteen patients had a negative serologic reaction for antibody to human T-cell leukemia virus type I (HTLV-I), and one patient was considered to be a HTLV-I carrier. Polyclonal hypergamma-globulinemia was observed in 6 patients, and 6 of the 12 patients showed elevated IgE levels. Immunophenotyping of the involved lymph nodes revealed a preponderance of T-cells in all the patients. Eleven of these patients showed a predominance of CD4+ over CD8+ T-cells, and only one patient showed a predominance of CD8+ over CD4+ T-cells. Two of five patients whose gene analysis was carried out showed clonal rearrangement of the T-cell receptor beta chain gene without rearrangement of the immunoglobulin heavy chain genes. Twelve patients received doxorubicin-containing combination chemotherapy; of these, 7 patients achieved complete response, and the other 5 had partial response. Nine patients are still alive with a median follow-up period of 21 months, and five patients died during the follow-up period. Progression to high-grade T-cell lymphoma with systemic infiltration was ascertained in two of three cases for which autopsy was performed. From our experience, we recommend doxorubicin-containing combination chemotherapy as initial therapy for AIL-related lesions.

Clonality of angioimmunoblastic lymphadenopathy and implications for its evolution to malignant lymphoma

To investigate the relationship of the lymphoid hyperplasia of angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) to supervening malignant lymphoma, we subjected DNA from lymph nodes and peripheral blood mononuclear cells from five AILD patients to Southern blot analysis to detect clonal rearrangements of immunoglobulin and T-cell receptor genes. Lymph nodes and peripheral blood from AILD patients were found to contain clones of lymphoid cells harboring either immunoglobulin or T-cell receptor gene rearrangements that, in some instances, regressed during the course of disease. A lymph node from one patient was involved by immunoblastic lymphoma and manifested an additional gene rearrangement pattern not seen in premalignant specimens from that patient. In contrast, DNA obtained from normal peripheral blood mononuclear cells and 11 examples of other forms of lymphoid hyperplasia showed no gene rearrangements. As a disorder of cellular immunoregulation in which lymphoid cells may escape normal growth controls, AILD provides a natural model to dissect stages of lymphomagenesis in man.

Prognostic factors in angioimmunoblastic lymphadenopathy

In order to identify prognostic factors in angioimmunoblastic lymphadenopathy (AIL), 30 directly diagnosed patients were prospectively followed for more than 42 months. Age and sex distribution, clinical and laboratory findings and evolution were not different from previously reported series. Median duration of survival was 24 months. Parameters associated with a longer survival in our series were localized adenopathies (P = 0.01) and the achievement of a remission (P less than 0.0001). Features associated with a shorter survival included drug exposure in relation to the onset of the disease (P = 0.02), rash (P less than 0.0001), lymph node eosinophilia (P = 0.03) and elevated serum lactic dehydrogenase (P = 0.03). Drug exposure and rash were, however, significantly dependent (P = 0.02). In addition, lymphopenia, the presence of circulating immune complexes, and the absence of polyclonal hypergammaglobulinemia may indicate a poor prognosis, although the significance level is not achieved in this short series. None of the parameters tested was significantly related to the lymphomatous transformation of AIL, which occurred in four cases. It is concluded that multicentric prospective studies of AIL are necessary in order to better define this disorder, to find prognostic factors, and to optimize therapy.

Peripheral T-cell lymphomas: histologic, immunohistologic, and clinical characterization

A review of 40 cases of peripheral T-cell lymphoma identified at our institution between March 1983 and December 1985 revealed a clinically, histologically, and immunologically diverse group of neoplasms that were difficult to classify by conventional histomorphologic criteria for non-Hodgkin's lymphomas. These lymphomas were frequently extranodal at the time of initial manifestation (52%), and their clinical aggressiveness correlated with three major histologic categories--small lymphocytic, diffuse mixed, and large cell. Of the 40 lymphomas, 18 exhibited distinctive histologic features that allowed assignment of these cases into one of four subgroups: (1) angioimmunoblastic lymphadenopathy, (2) lymphomatoid granulomatosis, (3) Hodgkin's-like disease, and (4) Lennert's lymphoma (lymphoepithelioid lymphoma). Study of all our cases that fulfilled the morphologic criteria for lymphomatoid granulomatosis or angioimmunoblastic lymphadenopathy by using immunologic methods for identification of B-cell and T-cell antigens has shown these neoplasms to be peripheral T-cell lymphomas. Therefore, we now consider these earlier proposed entities to be distinct histologic variants of peripheral T-cell lymphoma.

Angioimmunoblastic lymphadenopathy with dysproteinemia. Circulating immune complexes and the review of 18 cases

Eighteen patients with angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) have been analyzed by reviewing all available biopsy, laboratory, and clinical data. Because of features suggesting the presence of circulating immune complexes (CIC), CIC serial sample determinations were performed throughout their disease in available patients. Age, sex, and clinical and laboratory characteristics were consistent with previously reported series. Six of 18 (33%) patients having a drug exposure associated with onset or exacerbation of symptoms demonstrated a significantly decreased survival (P less than 0.02). Achievement of complete remission was a significant indicator of longevity (P less than 0.001). Only one patient (6%) developed diffuse histiocytic lymphoma. Elevated CIC were detected in the four patients tested. In two patients fluctuating CIC levels could clearly be correlated to clinical remission or exacerbation. Despite the small number of patients tested, it was concluded tha CIC may provide useful information for therapy selection, prediction of relapse, and further insight into pathogenetic mechanisms in AILD.

Histological, immunohistological and autopsy findings in lymphogranulomatosis X (including angio-immunoblastic lymphadenopathy)

172 cases of lymphogranulomatosis X (LgX) were studied by light microscopy. In 53 cases immunohistological techniques for detecting intracytoplasmic immunoglobulins were applied. In the lymph nodes of all cases the nodal architecture was found to be effaced. Active germinal centres were absent, and there was a generalized, markedly increased proliferation of epithelioid venules. A polymorphic infiltrate was present in all cases. It was dominated by immunoblasts in 14%, by plasma cells in 16%, by epithelioid cells in 23% and by lymphocytes in 6% of the cases. In the remaining 41% of the cases no special type of cell predominated (mixed cell type of LgX). The clusters of clear cells present in some cases with immunoblastic predominance did not stain for intracytoplasmic immunoglobulins; in contrast, the basophilic immunoblasts exhibited a polyclonal Ig pattern. In some of the cases with lymphocytic predominance most of the lymphocytes showed abundant cytoplasm with azurophil granules. Transformation into malignant lymphoma was proven at autopsy in 5 of 38 cases (13.2%). Malignant transformation (biopsy and autopsy material) was confirmed in a total of 11 of 172 cases (6.4%) and suspected in an additional 7%. Among the malignant lymphomas were one immunologically proven B-immunoblastic lymphoma, one peripheral T cell lymphoma and 5 cases of Hodgkin's disease. An association between LgX and carcinoma was histologically verified in 7 cases. 26 cases with active germinal centres and 11 cases with only locally pronounced vascularization but with histological and cytological changes that were otherwise similar to LgX were designated as hyperimmune reactions (HR). These cases had a significantly better prognosis. Two cases that presented as HR with active germinal centres later developed into LgX. It is suggested that the disappearance of active germinal centres is important in the pathogenesis of LgX. The possibility that this may correspond morphologically to an alteration of different components of the T-cell system is discussed.

Angioimmunoblastic lymphadenopathy associated with large-muscle arteritis

This is the reported case of angioimmunoblastic lymphadenopathy associated with large-muscle arteritis. Additional features included severe thrombocytopenia, IgG lambda paraproteinemia, and terminal staphylococcal and candidal infections.

Antivimentin autoantibodies in angioimmunoblastic lymphadenopathy

We evaluated the prevalence and specificity of smooth-muscle autoantibodies in 20 serum samples obtained from patients with angioimmunoblastic lymphadenopathy. Smooth-muscle antibodies in high titers were detected in 75 per cent of the samples. No such antibodies were found in 30 normal control serum samples or in 10 samples from patients with non-Hodgkin's lymphoma and 1 of 12 from patients with other types of polyclonal hypergammaglobulinemia were positive. The antibodies were polyclonal and belonged to the IgM, IgG, and IgA classes. They reacted with vimentin, the major polypeptide of the intermediate-filament cytoskeleton of mesenchymal cells. The pattern of tissue reactivity and absorption experiments both show that these antibodies recognize special antigenic determinants of the vimentin polypeptide that are shared by vimentin and other classes of intermediate-filament proteins - namely, keratin and desmin. The frequency of this unusual autoantibody activity in angioimmunoblastic lymphadenopathy suggests that, like hypergammaglobulinemia and a positive Coombs' test, it may represent a useful serologic marker for the disease.

De novo disseminated intravascular coagulation in angioimmunoblastic lymphadenopathy (AILD)

An elderly woman with angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) presented de novo with DIC in the absence of other etiologic causes for DIC. Complete reversal of the defibrination process occurred with vincristine, methyl-prednisolone, and heparin therapy. This case illustrates that defibrination can occur de novo in the presence of a clinically, although not pathologically, malignant process. AILD should be considered in the differential diagnosis of DIC.