Lymphosarcoma cell leukemia and other non-Hodgkin's lymphomas in leukemic phase

Characteristics and outcomes of diffuse large B-cell lymphoma presenting in leukaemic phase

Diffuse large B-cell lymphoma (DLBCL) occasionally presents with circulating malignant cells. The clinical characteristics and long-term outcomes of these patients have not been described. Twenty-nine newly diagnosed DLBCL presenting in leukaemic phase were identified between 1996 and 2010, at two institutions. Median age was 48 years, and patients presented with leucocytosis, high lactate dehydrogenase levels, B symptoms, and high International Prognostic Index score. Extra nodal site involvement was observed in all patients and affected the bone marrow (100%), spleen (62%), pleura/lung (41%), liver (21%), bone (17%), bowels (7%) and cerebrospinal fluid (14%). Blood lymphomatous cells co-expressed CD19, CD20, CD22, CD38, CD45, HLA-DR and FMC7 in >90%, and kappa or lambda light chain restriction in >50%. Ninety per cent received rituximab and anthracycline-based chemotherapy. Overall, remission was complete in 54% and partial in 31%; 15% had resistant disease. Median follow-up was 47 months; 13 (45%) patients remain alive in complete remission. Median progression-free and overall survivals were 11·5 and 46·7 months, respectively. In summary, patients with DLBCL in leukaemic phase present with high tumour burden and frequent involvement of extra nodal sites. In this uncommon DLBCL subgroup, anthracycline-based regimens with rituximab are associated with early morbidity and mortality, but yield approximately 50% 4-year survival.

Peripheral blood manifestations of lymphoma and solid tumors

Although the peripheral blood film has limited use in this age of technologic testing, most new tests are ancillary and cannot be interpreted accurately without examining the peripheral blood film. The peripheral smear plays a critical role in the diagnosis and management of many lymphoproliferative disorders, although playing more of a general function in nonlymphoid malignancies to evaluate cytopenias.

Biology of the neoplastic lymphocyte in B-CLL

Immunological markers have identified the proliferating lymphocyte in CLL as a mature B lymphocyte which, unlike lymphocytes in other B cell malignancies, expresses low amounts of surface membrane immunoglobulin (smIg), forms rosettes with mouse erythrocytes and expresses the CD5 marker. It has been postulated that Ly1 B cells (the murine counterpart of human CD5+B cells) constitute a separate B cell lineage. Whether the CD5 marker defines a discrete lineage or is a maturation marker is one of the main issues that might be solved in the near future. Another recent advance has been the discovery that the B lymphocyte in CLL is in an activated state and can be induced to differentiate. Using B cell mitogens and somatic hybridization, it has been demonstrated that the B-CLL lymphocyte is frequently involved in the production of natural autoantibodies and expresses a restricted set of genes. These results may provide a basis for passive immunotherapy using anti-idiotypic antibodies. Hypogammaglobulinaemia is a distinct feature of B-CLL, observed in 60% of patients. It may result from impaired function of residual normal B cells. This could occur as a consequence of progressive dilution of normal non-clonal B cells, or because normal B cells are downregulated by an unknown mechanism. This decrease in or inhibition of normal CD5-B cells could also explain the classical inability of patients with B-CLL to respond to new antigenic challenges, since Ly1 B cells have been claimed to be unable to respond to exogenous antigens. Although regulatory abnormalities in T cells may play a role in the induction of hypogammaglobulinaemia, data concerning helper, suppressive, NK and ADCC cells are contradictory and fail to establish firmly the contribution of these cells in the development of hypogammaglobulinaemia. Associated autoimmune phenomena are a prominent complication in CLL. They are related to the presence of autoantibodies directed mainly against blood components, which in most cases are not the product of the malignant clone. The relationship between autoimmune phenomena and hypogammaglobulinaemia is not definitively substantiated. That hypogammaglobulinaemia may determine the loss of some anti-idiotypic antibodies designed to antagonize autoimmune clones is an attractive hypothesis, which needs to be substantiated. Several recurrent chromosomal abnormalities, such as trisomy 12, structural aberrations of the 13q14 and 14q32 bands, are frequently observed in B-CLL. Less frequently, alterations of chromosomes 11, 6, 18, 3, 17, 7 and 8 have been reported.(ABSTRACT TRUNCATED AT 400 WORDS)

Chronic leukaemias

In recent years many subtypes of CLL and some CML variants have been recognized throughout the world by means of careful clinical, epidemiological, immunological, molecular biological and viral studies. Most striking has been the establishment of a close association between certain immunophenotypical subtypes of CLL and infection with HTLV-I and possibly HTLV-II. CLL has consistently been shown to have a strong genetic component and a low incidence among Asians, but a growing body of evidence also links this major leukaemia type with environmental factors including solvents, unidentified farming and other occupational exposures. In contrast, CML is characterized by few genetic associations, relatively homogenous world-wide distribution, greater frequency in Blacks than in Whites, little evidence of viral aetiology, and evidence that exposures to ionizing radiation, benzene and possibly other chemical agents are important aetiological factors. Most studies suggest that acquired rather than genetic factors are of greater importance in the aetiology of CML, but this conclusion is somewhat difficult to reconcile with the relatively small variation in incidence rates internationally. Common to both disorders in most populations are an increasing incidence with age, male predominance, and stability of incidence, survival and mortality over the years, exclusive of improved survival of CML following allogeneic bone marrow transplantation.

Hyperventilation as the initial manifestation of lymphomatous meningitis

We present the case of a 57 year old man who developed a B-cell lymphoma which involved his lymph nodes, liver, spleen, bone marrow, and peripheral blood. Shortly after attaining a complete remission with chemotherapy, the patient developed profound hyperventilation with no apparent cardiac or pulmonary cause. After one month, the patient developed a 7th nerve palsy and a subsequent work-up demonstrated that he had lymphomatous meningitis. The hyperventilation resolved completely with intrathecal chemotherapy, although the patient eventually died of widely disseminated lymphoma.

Clinical significance of hematologic parameters in non-Hodgkin's lymphoma at diagnosis

Three hundred seventeen patients with non-Hodgkin's lymphoma (NHL) (54 low grade, 180 intermediate grade, 76 high grade, and seven unclassified) treated with chemotherapy were evaluated for the presence of hematologic abnormalities at diagnostic staging. Anemia was present in 42%, leukopenia in 6%, thrombocytopenia in 13%, leukocytosis in 26%, and thrombocytosis in 14% at presentation. The presence of bone marrow involvement by lymphoma was more likely to be associated with leukopenia and thrombocytopenia than the absence of bone marrow involvement. Although anemia was slightly more common in patients with bone marrow lymphoma than in those without marrow lymphoma, the difference was not statistically significant. Hematologic parameters were similar for patients with B-cell or T-cell lymphoma. Evidence of bone marrow failure with multiple cytopenias was present in 26 patients (8%). Leukoerythroblastosis was present in 2%. Circulating lymphoma was present in 9.5%. Anemic patients had a shorter survival time than nonanemic patients, whether bone marrow was involved by lymphoma or not. Survival was not affected by the presence of leukopenia or mild leukocytosis, but, in patients without marrow lymphoma, leukocytosis with a leukocyte count greater than 20 x 10(9)/l was associated with short survival length. Thrombocytopenia was associated with short survival time only in patients with bone marrow involvement by lymphoma. Patients with multiple cytopenias or leukoerythroblastosis had short survival times, but the presence of circulating lymphoma did not alter survival when compared with other patients with bone marrow involvement by lymphoma. These data suggest that hematologic evaluation at the time of diagnostic staging of NHL provides useful prognostic information that may have therapeutic implications.

Role of immunotyping in chronic lymphocytosis: review of the natural history of the condition in 145 adult patients

We investigated the clinical value of immunotyping in 145 consecutive adult patients with absolute or relative lymphocytosis: 132 (91%) had B-cell lymphocytosis, 5 (4%) had T-cell lymphocytosis, 2 (1%) had hairy cell leukemia, and 6 (4%) had reactive lymphocytosis. Of the five patients with T-cell lymphocytosis, four were best categorized as having T gamma-chronic lymphoproliferative disease and had an indolent clinical course. Of the 132 patients with B-cell lymphocytosis, 121 (92%) had B-cell chronic lymphocytic leukemia (B-CLL), and 11 (8%) had small cleaved ("lymphosarcoma") cell leukemia. Patients with small cleaved cell leukemia had a worse clinical outcome than did those with B-CLL. We further analyzed the surface immunoglobulin (sIg) and CD20 (B-1) antigen expression patterns in B-CLL to determine whether any correlation existed with clinical outcome. A subset of patients with B-CLL in whom sIg was expressed in less than 20% of their lymphocytes had the best clinical outcome. HLA-DR (Ia-like) antigen typing helped identify B-CLL cases with minimal or no sIg expression. CD20 (B-1) antigen was weak or undetectable in most cases of B-CLL. Patients with B-CLL who had CD20 (B-1) in more than 20% of their lymphocytes did not have a different prognosis. Our data provide the incidence and natural history of the various subsets of CLL in a series of patients at a single institution. The type and extent of immunotyping necessary and practical in the clinical management of patients with CLL are explored.

Flow cytometric characterization of chronic lymphocyte leukaemias using orthogonal light scattering and quantitative immunofluorescence

Light scattering properties and antigen distribution of lymphocytes labeled with the monoclonal antibodies CD 5 and CD 20 were determined for 19 patients with a chronic B-cell derived leukaemia. The density of the antigen detected by the monoclonal antibody CD 5 appeared to be considerably lower on malignant B-lymphocytes of the patients as compared with T lymphocytes. A large variation was observed in the amount of receptors for the monoclonal antibodies CD 5 and CD 20 on the malignant cells of the different patients. B-cell chronic lymphocytic leukaemia (B-CLL) patients were clearly distinguishable from leukaemic follicular non Hodgkin lymphoma patients (LF-NHL, formerly lymphosarcoma cell leukaemia) and from a patient with a prolymphocytoid transformation (PLT) of the B-CLL according to the amount of the antigens for CD 5 and CD 20. Within the B-CLL patient population, no relation of progression of the disease with distribution of these antigens could be observed. In one patient the extraordinary phenotype CD 20+, CD 11+, leu 8+, CD 5- of the malignant lymphocytes was observed. An experimentally simple method to differentiate between the various chronic lymphocytic leukaemias (CLL) appeared to be the determination of orthogonal light scattering properties of lymphocytes. In healthy donors one can always distinguish two populations of lymphocytes in the orthogonal light scatter histograms. Lymphocytes of B-CLL patients show one uniform population with a relatively small orthogonal light scattering signal, lymphocytes of our patients with PLT of B-CLL or with LF-NHL show one uniform population with a relatively large orthogonal light scattering signal.

T-cell lymphoma revealed by a peripheral neuropathy. A report of two cases with an immunohistologic study on lymph node and nerve biopsies

In two patients a peripheral neuropathy was the presenting symptom of a noncutaneous peripheral T-cell lymphoma. In the first patient, the neuropathy had a relapsing and remitting course, the symptoms improved under corticosteroid therapy. The second patient suffered from a relentless neuropathy. In both cases the lymphoma infiltrated the peroneal nerve with an angiocentric and perivascular pattern resembling that observed in central nervous system lymphomas. The characterization of T-cell subsets in the lymph node showed cells with the helper/inducer and suppressor/cytotoxic phenotype in the first case and a predominance of cells with the helper/inducer phenotype in the second case. In the nerve, lymphocytes beard the helper/inducer phenotype antigen. A typical paraneoplastic vasculitis of nerve showed clearly different immunologic features.

Well-differentiated lymphocytic lymphoma with peripheral blood involvement, osteolytic bone lesions, and hypercalcemia. A case report and review of the literature

It is rare for small lymphocytic B-cell malignancies to be associated with osteolytic bone lesions and/or hypercalcemia. The authors present an unusual case of well-differentiated lymphocytic lymphoma (DWDL) in a 70-year-old man who had osteolytic bone lesions and subsequently developed severe refractory hypercalcemia. The possible etiologic mechanisms responsible for these findings are discussed, and a brief review of the literature is presented.

Canine lymphoma

This article presents an overview of the literature regarding canine malignant lymphoma. It includes a discussion of etiology, classification, systemic manifestations of disease, therapy, and supportive care for patient management.