Epstein-Barr virus (EBV) genome carrying monoclonal B-cell lymphoma in a patient with adult T-cell leukemia-lymphoma

Primary Cutaneous Composite Lymphomas

Composite lymphomas have been defined as 2 distinct subtypes of lymphoma occurring at a single anatomic site. Composite lymphomas limited to the skin are a rare occurrence and pose a unique challenge. Many reported cases within the skin are combined B-cell and T-cell lymphomas, typically mycosis fungoides and a low-grade B-cell lymphoma. These cases are challenging to recognize because lymphoid infiltrates within the skin often include a mixed population of B cells and T cells. In particular, reactive lymphoid proliferations (pseudolymphomas), primary cutaneous low-grade B-cell lymphomas, and primary cutaneous CD4+ T-cell lymphoproliferative disorder may show nearly equal numbers of B cells and T cells. In order to exclude these possibilities, overwhelming evidence in support of each lymphoma is helpful, including abnormal architecture, cytology, and immunophenotype, as well as molecular genetic evidence of clonality.

Epstein-Barr virus-related diffuse large B-cell lymphoma in mogamulizumab-treated adult T-cell leukemia with incomplete T-cell reconstitution

Adult T-cell leukemia (ATL) is an aggressive mature T-cell malignancy with a poor prognosis. The anti-C-C motif chemokine receptor 4 (CCR4) antibody mogamulizumab (moga) reduces ATL cells and induces reconstitution of polyclonal T cells; however, ATL cases often remain resistant and moga sometimes causes fatal immunopathology. Epstein-Barr virus (EBV)-related B-cell lymphoma develops in severely immunocompromised subjects, and is particularly associated with impaired T-cell immunity. Here, we report an ATL patient who had received conventional chemotherapy plus moga, and subsequently developed EBV-related diffuse large B-cell lymphoma (DLBCL) of the central nervous system. Next-generation sequencing-based T-cell receptor repertoire analyses identified residual abnormal clones and revealed that reconstitution of polyclonal T cells was incomplete, even after moga treatment. Furthermore, a skin rash that developed after moga treatment was found to contain ATL clones. This case suggests that the limited therapeutic effects of moga and incomplete T-cell reconstitution are associated with severely impaired T-cell immunity and subsequent development of EBV-related DLBCL.

Epstein-Barr virus-associated post-transplant lymphoproliferative disorders after allogeneic peripheral blood stem cell transplantation for Hodgkin-like adult T-cell leukemia/lymphoma

A 56-year-old woman with Hodgkin-like adult T-cell leukemia/lymphoma was treated with allogeneic peripheral blood stem cell transplantation on 17 April 2009. She manifested a moderate fever on day 41. CT scanning and other examinations detected slightly swollen lymph nodes, and pathological findings of right axillary lymph nodes revealed an Epstein-Barr virus-associated post-transplant lymphoproliferative disorder. She was successfully treated with rituximab.

Diffuse large B-cell lymphoma in human T-lymphotropic virus type 1 carriers

We describe the clinical and pathological characteristics of seven patients who were human T-lymphotropic virus type 1 (HTLV-1) carriers and had a pathological diagnosis of de novo diffuse large B-cell lymphoma. Interestingly, three of our cases showed positive expression of Epstein-Barr-virus, (EBV-) encoded RNA within the tumor cells indicating a possible interaction between these two viruses. Furthermore, our three EBV-positive cases presented with similar clinical characteristics such as early clinical stage and low-risk indices. To the best of our knowledge, this is the first case series describing the characteristics of HTLV-1-positive DLBCL patients. The potential relationship between HTLV-1 and EBV should be further explored.

Epstein-Barr virus-associated primary central nervous system lymphoma in a patient with adult T-cell leukemia / lymphoma

We present a case of Epstein-Barr virus (EBV)-associated primary central nervous system lymphoma (PCNSL) arising from a patient with cutaneous-type adult T-cell leukemia/lymphoma (ATLL). Extranodal sites affected by ATLL include the skin, lung, liver, gastrointestinal tract and central nervous system (CNS). CNS involvement usually occurs as an acute and lymphoma-type ATLL. PCNSL is a rare type of tumor and the vast majority of PCNSL are of B-cell lineage. Individuals with acquired, iatrogenic or congenital immunodeficiency are at increased risk of PCNSL, which is commonly associated with EBV. In our patient, the expression of latent infection membrane protein 1 (LMP1), EBV nuclear antigen 2 (EBNA2), and EBV-encoded small RNA (EBER) in tumor cells confirmed a type III latency of EBV infection. Human T-cell lymphotropic virus type I (HTLV-I) can induce immunodeficiency before the overt development of ATLL. The HTLV-I infection led to suppression of the immune system and the development of EBV-associated PCNSL. This is the first reported case of the clinicopathological features of EBV-associated PCNSL arising from a patient with ATLL.

EBV-positive diffuse large B-cell lymphoma in a human T-lymphotropic virus type 1 carrier

The development of B-cell lymphomas has been seldom described in HTLV-1 carriers. We present the case of an elderly Peruvian HTLV-1 carrier who was diagnosed with EBV-positive diffuse large B-cell lymphoma. Despite an initial good response to therapy, patient died during treatment due to fatal Pneumocystis jirovecci pneumonia. EBV infection is characterized by B-cell lymphotropism and selective immunodeficiency. HTLV-1, on the other hand, induces T-cell dysfunction and B-cell proliferation. Finally, immunosenescence is characterized by T-cell dysregulation, decreased apoptosis and cytokine upregulation. In this elderly patient, the combination of EBV and HTLV-1 coinfection and immunosenescence may have played a role in the development of this aggressive diffuse large B-cell lymphoma. Furthermore, the immunodeficiency caused by the viral infections and chemotherapy may have played a role in developing life-threatening infectious complications.

Epstein-Barr virus-associated proliferative disorder presenting as Hodgkin's lymphoma and developing as aggressive natural killer-cell leukemia 19 years later: a case report of composite lymphoma

We describe a patient who was diagnosed as having classic Hodgkin's lymphoma at 29 years of age, and aggressive natural killer-cell leukemia at 48 years. He died 42 days later. Hodgkin and Reed-Sternberg cells in the lymph node expressed CD30, CD15, T-cell intracellular antigen-1 (TIA-1), perforin, granzyme B, and Epstein-Barr virus-encoded RNA (EBER). Natural killer-cell leukemia cells in the bone marrow expressed cytoplasmic CD3epsilon, TIA-1, perforin, granzyme B, and EBER, and some neoplastic cells expressed CD56 (123C3). Fluorescence-activated cell sorter (FACS) analysis showed that neoplastic cells expressed CD56. Neither a rearrangement band of the T-cell receptor gene nor that of the immunoglobulin heavy chain gene was detected. Chromosomal abnormalities were noted.

The relationship of FOXP3 expression and clinicopathological characteristics in adult T-cell leukemia/lymphoma

Adult T-cell leukemia/lymphoma is an aggressive malignant disease associated with regulatory T cells as discussed in some recent reports. We analyzed the expression of FOXP3, a key molecule of regulatory T cells, in adult T-cell leukemia/lymphoma and its association with clinicopathological features. Of 169 adult T-cell leukemia/lymphoma cases examined, 60 (36%) showed FOXP3 expression in lymphoma cells. Morphologically, 22 cases were classified as anaplastic large cell variant and 147 as pleomorphic cell variant. Only 1 (5%) of the anaplastic large cell variant cases and 59/147 (40%) of the pleomorphic cell variant cases expressed FOXP3. Epstein-Barr virus-infected cells were significantly more frequently found in FOXP3(+) cases (23/60; 38%) than in FOXP3(-) cases (12/109; 11%) (P<0.0001). Cytogenetic analysis showed that FOXP3(+) cases had simpler chromosomal abnormalities than FOXP3(-) cases. Clinically, FOXP3(+) and FOXP3(-) cases did not differ significantly in age distribution, clinical stage, lactate dehydrogenase and calcium in serum and overall survival. However, 8 of 34 FOXP3(+) cases suffered a severe infectious state, an indication of immunosuppression, while only 2 of 62 FOXP3(-) cases did so (P<0.005). FOXP3 expression in adult T-cell leukemia/lymphoma thus reflects morphological features and is clinically and pathologically associated with an immunosuppressive state.

Epstein-Barr Virus Negative Clonal Plasma Cell Proliferations and Lymphomas in Peripheral T-cell Lymphomas

Clonal B-cell populations have been described in peripheral T-cell lymphomas (PTCL) as secondary Epstein-Barr virus (EBV) driven B-cell expansions that may evolve to an overt B-cell lymphoma. EBV-negative B-cell proliferations associated with T-cell lymphomas are uncommon and not well characterized. We studied 15 patients who developed an EBV-negative B-cell proliferation or malignant lymphoma associated with PTCL. The T-cell tumors were 8 PTCL, not otherwise specified, 4 angioimmunoblastic T-cell lymphomas, and 3 cutaneous PTCL. The B-cell component was intermingled with the PTCL in all patients and it was classified as clonal/monotypic plasma cell proliferation in 8 lesions, clonal/monotypic large B-cell proliferation in 4 patients, and B-cell lymphoma with plasmacytic/plasmablastic differentiation in 3 patients. Two patients had 2 clonally unrelated plasma cell proliferations associated with the same PTCL. All cases showed cytoplasmic Ig light chain restriction. Clonal IgH and T-cell receptor rearrangements were detected in 11/12 and 11/13 cases examined, respectively. EBV, cytomegalovirus, and HHV-8 were not observed in any of the examined cases. Sequential samples in 7 patients showed persistence of the PTCL and the B-cell component in 4, the PTCL without the B-cell lymphoma in 2, and progression of the B-cell neoplasm in 1. Patients followed an aggressive clinical course similar to conventional PTCL. In conclusion, EBV-negative clonal or mononotypic B-cell proliferations in patients with PTCL present with a spectrum of lesions ranging from plasma cell proliferations to overt lymphomas with plasmacytic/plasmablastic features. The distinctive features of these patients suggest that these lesions represent a specific phenomenon in PTCL.

Composite EBV negative peripheral T-cell lymphoma and diffuse large B-cell lymphoma involving the ileum: a case report and a systematic review of the literature

We report a case of an intestinal peripheral T-cell lymphoma (PTCL) with a concurrent diffuse large B-cell lymphoma (DLBL) involving the ileum and a regional lymph node. The patient presented with an abdominal mass. The terminal ileum showed a diffuse and monotonous population of small CD3-positive T cells. The T-cell receptor gamma (TCRgamma) gene was rearranged by PCR while the immunoglobulin heavy chain (IgH) gene was not. A separate section of the ileum showed a colliding large B-cell proliferation. The regional lymph node showed a diffuse proliferation of large centroblasts positive for CD20 and CD79a admixed with small T cells and showed a rearranged IgH receptor gene without evidence of a clonally rearranged TCRgamma gene. Both the PTCL and DLBL components were negative for EBV. A review and analysis of the pertinent literature describing composite T- and B-cell lymphomas is performed and reported.

The spectrum of cutaneous lymphomas in Japan: a study of 62 cases based on the World Health Organization Classification

BACKGROUND

The relative incidence of malignant lymphoma subtypes differs according to geographic location. This study investigated the epidemiology of cutaneous lymphoma subtypes in Japan and compared it with other countries.

METHODS

Sixty-two patients with cutaneous lymphoma attending the Department of Dermatology, National Hospital Organization Hokkaido Cancer Center were reviewed. The World Health Organization classification of hematopoietic and lymphoid malignancies was adopted.

RESULTS

Of the 62 patients, 31 had primary cutaneous lymphoma (PCL) and 31 had secondary cutaneous lymphoma (SCL). T- and natural killer (NK)-cell lymphoma accounted for 80% of PCL, of which, mycosis fungoides accounted for almost 35%. Of the 31 patients with secondary cutaneous lymphoma, 17 patients (54%) had T- and NK-cell lymphoma, including nine adult T-cell leukemia/lymphoma patients, and 14 patients (46%) had B-cell lymphoma, including 11 diffuse large B-cell lymphoma patients. The majority of patients with SCL and NK-cell lymphoma with primary or secondary skin lesions had a poor outcome.

CONCLUSIONS

PCL in this study showed a similar incidence to that of other institutions in Japan, while also demonstrating different frequencies from that of other countries, suggesting that the relative frequency of different PCL subtypes differ according to geographical location, similar to previous reports of systemic malignant lymphoma.

Successful Treatment of Refractory Peripheral T-Cell Lymphoma with a Combination of Fludarabine and Cyclophosphamide

We report a case of refractory peripheral T-cell lymphoma (PTCL) successfully treated with a combination of fludarabine and cyclophosphamide (FLU/CY). A 68-year-old man with concurrent PTCL and diffuse large B-cell lymphoma was treated effectively with 3-course CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisolone) therapy, but PTCL relapse occurred and was resistant to ESHAP (etoposide, methylprednisolone, cytarabine, and cisplatin) therapy. FLU/CY therapy led to complete remission, which was maintained for almost 14 months after a single course. We concluded that a FLU/CY regimen may be useful for attaining long-term remission in patients with refractory relapsed PTCL and should therefore be considered a valuable treatment choice.

Burkitt lymphoma of the uterus in a human T lymphotropic virus type-1 carrier

A 71-year-old Japanese woman who was seropositive for T-lymphotropic virus type-1 (HTLV-1) developed primary Burkitt lymphoma of the uterus. CT showed marked enlargement of the uterine body. Chromosomal abnormalities were detected in biopsied cells, and most showed the t (8; 14) (q24; q32) translocation. Fluorescence in situ hybridization (FISH) with a dual-color stain for IgH/C-MYC fusion showed 99% positively. Biopsies from abdominal operation were diagnosed as Burkitt lymphoma. Treatment was started with intensive chemotherapy according to a protocol for Burkitt lymphoma and mature-B cell leukemia. Two regimens were done with four courses with rituximab. Treatment response was fast, with a documented and lasting first complete remission on CT and laboratory markers after the 4 cycle treatment.

Metachronous extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) and peripheral T-cell lymphoma unspecified: histologic, immunophenotypic, and molecular documentation

BACKGROUND

Coexistence of B- and T-cell lymphoid malignancies has been reported sporadically.

CASE REPORT

A 68-year-old woman developed a lymphoid neoplasm in the large intestine and a second lymphoid neoplasm in the esophagus, 24 months after the diagnosis of the first lymphoma. Immunophenotypic analyses were consistent with extranodal marginal zone B-cell mucosa-associated lymphoid tissue type (MALT type) and peripheral T-cell unspecified lymphomas in the large intestine and the esophagus, respectively. The molecular analysis confirmed the B-clonal genotype of the first lymphoma, and disclosed a biclonal genotype of the second one (composite T- and B-cell lymphoma). No evidence of Epstein-Barr virus (EBV) association was shown in either tumor.

CONCLUSION

B- and T-cell neoplasms represent two distinct malignancies rather than progression of the same neoplastic clone.

Human T-cell leukemia virus type I (HTLV-I) infection and the onset of adult T-cell leukemia (ATL)

The clinical entity of adult T-cell leukemia (ATL) was established around 1977, and human T-cell leukemia virus type 1 (HTLV-I) was subsequently identified in 1980. In the 25 years since the discovery of HTLV-I, HTLV-I infection and its associated diseases have been extensively studied, and many of their aspects have been clarified. However, the detailed mechanism of leukemogenesis remains unsolved yet, and the prognosis of ATL patients still poor because of its resistance to chemotherapy and immunodeficiency. In this review, I highlight the recent progress and remaining enigmas in HTLV-I infection and its associated diseases, especially ATL.

Current views in HTLV-I-associated adult T-cell leukemia/lymphoma

Epidemiological studies have demonstrated that the relative percentage of malignant lymphoid proliferations varies widely according to geographical location and ethnic populations. HTLV-I is the etiological agent of adult T-cell leukemia/lymphoma (ATLL) and is also associated with cutaneous T-cell lymphoma (CTCL). However, a definite role of HTLV-I in mycosis fungoides (MF) and/or Sezary syndrome (SS) remains controversial. While most HTLV-I-infected individuals remain asymptomatic carriers, 1-5% will develop ATLL, an invariably fatal expansion of virus-infected CD4+ T cells. This low incidence and the long latency period preceding occurrence of the disease suggest that additional factors are involved in development of ATLL. In this review, diagnosis, clinical features, and molecular pathogenesis of HTLV-I are discussed.

Epstein-Barr virus-associated composite lymphoma composed of peripheral T-cell lymphoma and an anaplastic variant of a diffuse large B-cell type of non-Hodgkin's lymphoma and strongly expressing p53 protein

We report a case of composite lymphoma consisting of peripheral T-cell lymphoma and an anaplastic variant of diffuse large B-cell lymphoma (DLBCL) and associated with Epstein-Barr virus (EBV) infection and strong p53 expression. A 65-year-old Japanese woman developed fever and generalized lymphadenopathy. A biopsy of the cervical node revealed the morphology of malignant lymphoma with 2 kinds of lymphoma coexisting in 1 lymph node. One lymphoma type consisted of immunoblastic large cells with the T-cell marker phenotype CD3+, CD45RO/UCHL-1+, CD20/L26-, CD79-, CD10-, CD30-, and CD15-; the other type consisted of large cells with abundant cytoplasm and pleomorphic nuclei with the marker phenotype CD79+, CD20/L26+, CD45RO/UCHL-1-, CD3-, CD10-, CD30+, NPM/ALK-, and CD15-. Therefore, the diagnosis was composite lymphoma of peripheral T-cell lymphoma and an anaplastic variant of DLBCL, stage IVB, because the patient had bone marrow involvement with peripheral T-cell lymphoma. The biopsy led to findings of latent type II EBV-associated lymphoma in both the peripheral T-cell lymphoma and the anaplastic variant of DLBCL as the result of positive signals for EBV small RNAs by in situ hybridization, positive immunostaining results for EBV latent membrane protein 1 antibody, and negative immunostaining results for EBV nuclear antigen 2. Immunostaining of the mass with p53 antibody also yielded positive results for both types of lymphoma cells. This case suggests that the immunocompromised state of this patient with EBV-related peripheral T-cell lymphoma allowed the emergence of an EBV-related anaplastic variant of DLBCL and suggests a close relationship between p53 expression and latent EBV infection.

Composite lymphoma: angiocentric T-cell lymphoma (CD8+ cytotoxic/supressor T-cell) and diffuse large B-cell lymphoma associated with EBV, and presenting clinically as a midfacial necrotizing lesion

A composite lymphoma is defined as the simultaneous occurrence of two histologically different types of lymphomas situated in one anatomical location. Reports of composite B- and T-cell lymphomas, especially in the head and neck region, are rare. We describe a 76-year-old Taiwanese aboriginal female patient clinically presenting with a midfacial necrotizing lesion (MNL). Microscopic examination of the incisional biopsy specimen revealed extensive surface necrosis with infiltrates of inflammatory cells. Beneath the necrotic surface, there appeared to be two distinct populations of pleomorphic lymphoid cells exhibiting the characteristic features of the angiocentric distribution of the tumor cells and evidence of angiodestruction. Immunohistochemical staining revealed that these atypical lymphoid cells were positive for LCA, CD45, CD5, CD20, CD3 epsilon, CD8, bcl-2 and bcl-6 and negative for CD56, CD4, CD68, keratin, S-100, kappa and lambda. Furthermore, these atypical lymphoid cells also expressed EBV-encoded nuclear RNAs (EBERs) following in situ hybridization. Therefore, this was a case of composite lymphoma: angiocentric T-cell lymphoma (ATCL) (CD8+ cytotoxic/suppressor T-cell) and diffuse large B-cell lymphoma (DLBL) associated with the Epstein-Barr virus (EBV) and presenting clinically as MNL.

HTLV-1 carriers with B-cell lymphoma of localized stage head and neck: prognosis, clinical and immunopathological features

Human T-lymphotropic virus type I (HTLV-I) is closely associated with T-cell lymphoma/leukaemia, which always shows monoclonal HTLV-1 provirus DNA integration. HTLV-1 is not associated with B-cell lymphoma. The relationship between B-cell lymphoma and HTLV-1 was analysed retrospectively in early stage B-cell non-Hodgkin's lymphoma (NHL) according to HTLV-1 infection and pathological features. We analysed 198 cases of head and neck B-cell NHL treated with radiotherapy and/or chemotherapy; 21 were seropositive and 177 were seronegative for HTLV-1. We also immunostained 26 cases of diffuse large B-cell lymphoma (DLBL), including 12 seropositive and 14 seronegative for HTLV-1 respectively, for CD20, CD3, CD4, CD8, CD56, MIB-1 and T-cell-restricted intracellular antigen (TIA-1) to examine the phenotype, immunity and proliferation activity. The 5-year overall survival rates were 78% and 49% (P = 0.007, log rank test) for HTLV-1 seronegative and seropositive cases respectively. Infection with HTLV-1 was significantly associated with poor survival in patients with B-cell lymphoma by multivariate analysis. For DLBL, HTLV-1 infection was not a significant factor, but the overall survival curve was similar to that of the 21 seropositive B-cell lymphoma cases. Lymphoma cells were negative for TIA-1, but the background lymphocytes were positive for this marker. The number of TIA-1-positive cells was higher in HTLV-1-negative cases than in-positive cases. In conclusion, patients with B-cell-NHL (B-NHL) who are also HTLV-1 carriers have a poorer prognosis than non-carriers. HTLV-1 does not seem to be associated with lymphomagenesis of the B phenotype itself, but correlates with host immunity by reducing the number of cytotoxic T-cells.

Human T-cell leukemia virus type I and adult T-cell leukemia

Human T-cell leukemia virus type I (HTLV-I) causes adult T-cell leukemia (ATL) in about 5% of carriers after a long latent period. After its infection, HTLV-I promotes the clonal proliferation of HTLV-I infected cells in vivo by actions of encoded viral proteins, including Tax. However, leukemic cells frequently lack the expression of Tax by the genetic and epigenetic changes of HTLV-I provirus, suggesting that Tax is not always necessary after transformation. Alternatively, ATL cells without Tax protein could escape from the host immune system since Tax is the major target of cytotoxic lymphocytes. During the latent period, alterations of host genome accumulate, finally leading to onset of ATL.

Composite angioimmunoblastic T-cell lymphoma and diffuse large B-cell lymphoma: a case report and review of the literature

We report a rare case of composite angioimmunoblastic T-cell lymphoma (AILT) and diffuse large B-cell lymphoma occurring in a 48-year-old woman with generalized lymphadenopathy and hepatosplenomegaly. The patient initially sought care at a local hospital with a single enlarged left cervical lymph node. Histologic examination of the node was interpreted as an atypical immunoblastic proliferation. She developed generalized lymphadenopathy 10 months later and was referred to our institution for further evaluation. The recent biopsy of the cervical node showed typical features of AILT Flow cytometric immunophenotyping identified an aberrant CD4+ T-cell population that lacked surface CD3. Polymerase chain reaction analysis of the T-cell receptor gamma gene revealed a clonal rearrangement. In addition to the AILT, the lymph node showed partial involvement by a diffuse large B-cell lymphoma. The B lymphoma cells and admixed immnunoblasts and Reed-Sternberg-like B cells in the AILT were positive for Epstein-Barr virus (EBV) by in situ hybridization. Ourfindings raise the possibility that the EBV-associated large B-cell lymphoma is a secondary event in AILT via EBV infection or reactivation followed by clonal expansion of an immortalized EBV-infected B cell clone.

Epstein-Barr virus-associated B-cell lymphoproliferative disorders in angloimmunoblastic T-cell lymphoma and peripheral T-cell lymphoma, unspecified

Various patterns of Epstein-Barr virus (EBV)-associated B-cell lymphoproliferation occur in patients with immunodeficiency. We studied 17 cases of T-cell lymphoma displaying extensive EBV-driven B-cell lymphoproliferation or simultaneous/subsequent EBV-associated B-cell lymphoma. In 10 cases of angioimmunoblastic T-cell lymphoma, an uncommonly prominent population of EBV+ atypical, activated, focally confluent large transformed B cells was found in the background of T-cell lymphoma. In 4 cases, an EBV-associated B-cell neoplasm (3 diffuse large B-cell lymphomas, 1 plasmacytoma) occurred in patients with T-cell lymphoma. Three cases were composite lymphomas of a peripheral T-cell lymphoma, unspecified, combined with EBV-associated diffuse large B-cell lymphoma. The transformed B-cell population displayed EBV latency types 2 and 3. Monoclonal and oligoclonal B-cell populations were detected in 5 and 6 cases, respectively. Similar to other states of immunodeficiency, disease-related and therapy-induced immunosuppression in T-cell lymphoma may lead to a prominent EBV-associated B-cell lymphoproliferation and to EBV+ B-cell neoplasms.

Impaired production of naive T lymphocytes in human T-cell leukemia virus type I-infected individuals: its implications in the immunodeficient state

Opportunistic infections frequently occur in patients with adult T-cell leukemia (ATL) and human T-cell leukemia virus type I (HTLV-I) carriers. However, the underlying mechanisms of such infections remain unknown. To clarify the mechanism of immunodeficiency in those infected with HTLV-I, this study analyzed the T-cell subsets in HTLV-I carriers and patients with HTLV-I-associated myelopathy/tropical spastic paraparesis and ATL using 3-color fluorescence with CD62L and CD45RA coexpression either with CD4(+) or CD8(+) T cells. The number of naive T lymphocytes was markedly suppressed in patients with ATL, particularly in those with acute form, compared with uninfected control individuals. The number of naive T cells was low in HTLV-I-infected individuals under 50 years old compared with uninfected individuals, whereas the number of memory T lymphocytes was greater in HTLV-I-infected individuals. Although the increase of memory T lymphocytes correlated with HTLV-I provirus loads, no relationship was found between naive T-cell counts and provirus loads. T-cell receptor rearrangement excision circles (TRECs), which are generated by DNA recombination during early T lymphopoiesis, were quantified to evaluate thymic function in HTLV-I-infected individuals. TREC levels were lower in HTLV-I-infected individuals than in uninfected individuals. In HTLV-I carriers less than 70 years old, an increase of Epstein-Barr virus DNA in peripheral blood mononuclear cells was observed in 6 of 16 (38%) examined, whereas it was detectable in only 1 of 11 uninfected controls. These results suggested that the low number of naive T lymphocytes was due to suppressed production of T lymphocytes in the thymus, which might account for immunodeficiency observed in HTLV-I-infected individuals.

Pathology of lymphoma progression

Reflecting the stepwise process of oncogenesis, lymphomas may cumulatively develop a more aggressive phenotype during the course of disease, a process referred to as lymphoma progression. Although morphological, clinical and biological aspects of lymphoma progression do not always overlap, changes in lymphoma morphology frequently indicate alterations in the clinical and biological behaviour of the disease. Indolent and aggressive lymphomas in disease progression can either be clonally related or represent clonally unrelated neoplasms. We propose to use the term 'lymphoma progression' in a biological sense denoting only clonal development of and within a lymphoma entity. The term 'composite lymphoma' should be used as a merely descriptive morphological designation for different lymphoma entities in one individual irrespective of clonal relationship. Many types of aggressive B-cell non-Hodgkin's lymphomas and Hodgkin's lymphomas are reported to secondarily develop in lymphoma progression. Genetic changes associated with lymphoma progression frequently abrogate the differentiating effects of alterations occurring in indolent lymphomas, leading to increased cell proliferation. Within different lymphoma entities, high-risk disease variants mimicking lymphoma progression exist.

Possible association between adult T-cell leukemia/lymphoma and acute myeloid leukemia

BACKGROUND

To the authors' knowledge, an association between adult T-cell leukemia/lymphoma (ATL) and acute myeloid leukemia (AML) has been reported only in four patients. The authors identified five additional patients with both neoplasms.

METHODS

A review of the clinical records of patients with AML, ATL, or lymphoid neoplasms other than ATL diagnosed between 1986 and 1995 was performed. Cytokine levels were assayed in selected patients. The authors searched for reports from other institutions using MEDLINE and the proceedings of two Japanese hematology societies.

RESULTS

ATL was diagnosed in 134 patients, whereas 180 had AML. Five patients with both neoplasms were identified (3.7% of ATL patients and 2.8% of AML patients). In seven of the nine patients (including four patients in the literature) with ATL and AML, the ATL was diagnosed prior to the AML, whereas in the remaining two patients both neoplasms were diagnosed simultaneously. Six of the nine cases were therapy-related (t)-AML, which developed after chemotherapy for ATL. Monoclonal integration of proviral human T-lymphotropic virus type 1 was detected in ATL cells but not in AML cells in the six patients examined. The plasma levels of macrophage colony-stimulating factor (M-CSF), granulocyte-colony stimulating factor, and granulocyte-macrophage-colony stimulating factor (GM-CSF) were elevated in 3, 1, and 1, respectively, of the 4 patients examined at AML onset who had active ATL. In one case, the levels of several cytokines, including GM-CSF and M-CSF, in the supernatant fluid of short term cultured ATL cells were elevated. Three patients with de novo ATL and AML received remission induction therapy, and two achieved a complete remission (CR) of both diseases. Among the four patients who received chemotherapy for t-AML, two achieved CR.

CONCLUSIONS

ATL patients also can develop AML, irrespective of treatment with chemotherapy for ATL. This association does not indicate exclusive chemoresistance of both neoplasms. Cytokines produced by ATL cells may support the growth of AML cells.

Epstein-Barr virus-associated Hodgkin's disease in HTLV-I seropositive patients: a report of two cases

Diagnosis of Hodgkin's disease (HD) is quite difficult in the patient with seropositivity for human T cell lymphotropic virus I (HTLV-I). Herein, two cases of Epstein-Barr virus (EBV)-associated HD, which occurred in males with seropositivity for anti-HTLV-I, are reported. One patient is alive and was diagnosed as having interfollicular HD with CD20+CD15-CD30-CD3-CD4-CD8-CD45RO-Read-Sternberg (R-S) cells. Positivity for EBV-encoded RNA 1 (EBER-1) and latent membrane protein 1 (LMP-1) was shown on follicular germinal center cells and R-S cells. In that case, neither T cell receptor (TCR) beta chain rearrangement nor integration of the HTLV-I provirus was demonstrated in the lymph nodes, although atyical lymphocytes (2%) were found in the peripheral blood. The other case pursued an aggressive clinical course and the patient was diagnosed as having an adult T cell leukemia/lymphoma (ATLL) because of the presence of anti-HTLV-I antibody, lymph node swelling, and the appearance of flower-like cells in the peripheral blood. However, an autopsy revealed no obvious ATLL cell infiltration in any of the organs examined. Multiple granulomatous lesions were found in the bone marrow, liver, kidneys, spleen, and lymph nodes. Reassessment of lymph node lesions in biopsies and granulomatous lesions in autopsy samples demonstrated that both lesions contained CD15+CD30+CD3-CD4-CD8-CD20-CD45RO-EBER-1+L MP-1+R-S cells, and they were considered to be a composite lymphoma of HD and ATLL. These two cases therefore suggest that EBV-associated HD can develop in patients with seropositivity for HTLV-I.

Mantle cell lymphoma with the features of mucosa-associated lymphoid tissue (MALT) lymphoma in an HTLV-I-seropositive patient

A case of small lymphocytic B-cell lymphoma with seropositivity for human T-cell leukemia virus type I (HTLV-I), whose clinical features were closely related to those of mucosa-associated lymphoid tissue (MALT) lymphoma, is presented. The neoplastic cells of the lymph node were immunologically positive for CD5, in addition to several B-cell markers, but negative for CD10, and cytogenetically carried a t(11;14)(q13;q32). These findings were fully consistent with so-called mantle cell lymphoma (MCL). In addition to the lymph nodes and bone marrow, multiple extranodal sites including lacrimal and salivary glands, lung and stomach (where MALT is present) were occupied by lymphoma cells. These extranodal lesions were immunologically identical to the lymph nodes (CD5(+), CD10(-)), but histologically showed lymphoepithelial lesions (LEL) characteristic of MALT lymphoma. These findings suggest a possible relationship between MCL and MALT lymphoma, and the neoplastic cells are thought to originate from the CD5-positive B cells, which are present near the areas across the mantle and marginal zones. Furthermore, HTLV-I-infection, which appears to create an immunodeficient state or modulate the B-cell response, is thought to play a role in B-cell lymphomagenesis.

Pyothorax-associated pleural lymphoma. A case evolving from T-cell-rich lymphoid infiltration to overt B-cell lymphoma in association with Epstein-Barr virus

BACKGROUND

Pyothorax-associated pleural lymphomas (PAPL) occur in patients with long-standing pyothorax. Epstein-Barr virus (EBV) plays an important role in its development.

METHODS

An atypical case of PAPL is reported and its clinical features are compared with those of five cases of ordinary PAPL.

RESULTS

The histology of the lymphoma changed from prominent T-cell infiltration to an overt B-cell lymphoma of diffuse, large cell-type. DNA studies of the lymphoma at the first presentation demonstrated dual rearrangement in the T-cell receptor beta (TCR beta) and immunoglobulin heavy chain J region (IgJH) genes. EBV genome analysis demonstrated monoclonal expansion of EBV-infected cells. EBV gene products were present only in large lymphocytes with B-cell phenotype. The same rearranged band of the IgJH gene, but not clonal rearrangement of the TCR beta gene, was observed in the overt B-cell lymphoma at the relapse. The same EBV-infected clone was observed throughout the course of the disease. The tumor was localized at the pyothorax wall, and cell-mediated immunity, reflected by a positive tuberculin reaction, was preserved only in the current case.

CONCLUSIONS

T-cell-rich lymphoid infiltration in the current case is a variant of EBV-associated PAPL, which is infiltrated by reactive T-cells with clonal accentuation. This is the first documented case of EBV-associated PAPL evolving from T-cell-rich lymphoid infiltration.