Multicentric giant lymph node hyperplasia: an immunohistochemical study

Is TAFRO syndrome a subtype of idiopathic multicentric Castleman disease?

Castleman disease (CD) is a rare lymphoproliferative disorder that can be unicentric or multicentric. Multicentric CD (MCD) is further subdivided into human herpesvirus type-8-associated, POEMS syndrome-associated, and idiopathic (iMCD). TAFRO syndrome is a newly identified disorder of unknown etiology characterized by thrombocytopenia, anasarca, fever, reticulin myelofibrosis, renal dysfunction, and organomegaly. The TAFRO syndrome is sometimes regarded as a subtype of iMCD (TAFRO-iMCD), whereas iMCD without TAFRO syndrome is considered "not otherwise specified" (iMCD-NOS). However, a proportion of patients with TAFRO syndrome have been diagnosed without lymph node biopsies (TAFRO syndrome without proven iMCD; TAFRO-w/op-iMCD). To clarify the clinical features of iMCD-NOS, TAFRO-iMCD, and TAFRO-w/op-iMCD, we retrospectively analyzed 220 patients extracted from the database of the Multicenter Collaborative Retrospective Study for Establishing the Concept of TAFRO Syndrome. The patients included 87 with iMCD-NOS, 63 with TAFRO-iMCD, and 19 with TAFRO-w/op-iMCD. Patients in all three groups exhibited anemia, hypoalbuminemia, and elevated serum C-reactive protein and interleukin-6 levels. No significant differences in clinical, laboratory, and prognostic features were noted between the TAFRO-iMCD, and TAFRO-w/op-iMCD groups. However, the iMCD-NOS group exhibited polyclonal hyper-γ-globulinemia. The five-year survival rates of patients in the iMCD-NOS and TAFRO-involved groups were 100% and 66.5%, respectively (dropping markedly during the first few months in the latter). The iMCD-NOS and the TAFRO-iMCD samples typically showed plasma cell and mixed-type histologies, respectively. Thus, iMCD can be classified into two distinct subtypes, iMCD-NOS and TAFRO-iMCD. As such, TAFRO-iMCD and TAFRO-w/op-iMCD may be considered the same entity, requiring prompt diagnosis and intensive care.

Pediatric Intraparotid Castleman's Disease

Castleman's disease (CD) is a rare, benign lymphoepithelial disease of unknown cause that presents most commonly in the mediastinum. There are 2 histologic types of CD: the hyaline vascular type and the plasma cell type. In the head and neck, 98% of these lesions are of the hyaline vascular type. The differential diagnosis of CD includes reactive lymphadenopathy, lymphoproliferative disorders, lymph node metastasis, and other conditions. Approximately 80 cases of CD have been reported in children; head and neck involvement in children is extremely rare. A case of a child with intraparotid CD is presented; the clinical course, histopathologic presentation, radiographic findings, and management of CD are reviewed.

Multicentric Castleman's disease representing effusion at initial clinical presentation: clinicopathological study of seven cases

We present here seven cases of idiopathic multicentric Castleman's disease (MCD) showing effusion at the initial clinical presentation. This series includes a high proportion of middle-aged and elderly females (5/7). Various autoantibodies were detected in six cases. Anemia (Hb < 10 g/dl) was detected in four cases, leukocytosis (WBC > 10 × 10(9)/l) in three and thrombycytopenia (<100 × 10(9)/l) in five. Positivity for C-reactive protein or elevated erythrocyte sedimentation rate was recorded in all seven cases. Elevated serum IgG level (>2000 mg/dl) was recorded in only three cases. Elevated serum interleukin-6 level was recorded in all four cases examined. At the onset of disease, four cases were associated with idiopathic thrombocytic purpura. During the course of disease, one case each was diagnosed as systemic sclerosis + Sjögren's syndrome (SJS) and SJS. Histologically, five lesions exhibited a mixed type of Castleman's disease, and one case each exhibited a hyaline-vascular type and plasma cell type. The non-neoplastic nature of the B-lymphocytes was demonstrated by immunohistochemistry and polymerase chain reaction. There were no human herpes type-8 virus-positive cells in any of the seven lesions. Good responsiveness to glucocorticoid therapy has been seen in all six cases treated. From a therapeutic perspective, it is important to discriminate this subtype of MCD.

[Cervical Castleman disease in childhood: a report of two cases and a review of the literature]

Castleman disease (CD) is a benign lymphoproliferative disorder, rare in children. Head and neck localizations are found only in 14 % of the cases. Two forms have been described: a hyaline vascular type and a plasma cell type. It can also be monocentric or multicentric. Both young patients were affected with an isolated neck localization of Castleman disease. Preoperative diagnosis can be difficult with a thymoma or a lymphoma. CT and MRI can help in the diagnosis, which is confirmed by histopathological assessment. The pathological features and the therapeutic management of CD are discussed. While surgery is the treatment for localized lesions, steroids and chemotherapy are indicated in the multicentric type. Because of the risk of relapse and malignant transformation, long-term follow-up is mandatory.

Intracranial Localized Castleman's Disease-Case Report-

A 68-year-old woman presented with generalized clonic seizure following a 2-month history of initiative loss, incoherent speech, headache, and left hemiparesis. No systemic signs or symptoms were seen and laboratory studies were within normal range. Computed tomography and magnetic resonance imaging demonstrated a well-delineated small mass with homogeneous enhancement in the right parietal convexity, associated with unusually extensive perifocal edema compared to the size of the mass. Cerebral angiography showed a faint stain fed by the middle meningeal artery. These imaging features were very similar to those of meningioma. Full recovery from the symptoms was achieved by total removal of the lesion and no recurrence was found after 3 years. Histological examination identified the hyaline-vascular type of angiofollicular lymph node hyperplasia (Castleman's disease). Castleman's disease involving the central nervous system is rare, with only 12 previous cases, but should be considered in the diagnosis of intracranial meningeal tumors. The treatment of choice for localized Castleman's disease is complete surgical resection, which is curative in most of the cases.

Systemic lupus erythematosus (SLE) lymphadenopathy presenting with histopathologic features of Castleman' disease: a clinicopathologic study of five cases

Lymph node enlargement is common in active systemic lupus erythematosus (SLE), a disease characterized by well defined clinical criteria. Although numerous reports have described the characteristic histology of SLE lymphadenopathy to include necrotizing lesions and hematoxylin bodies, no detailed description has examined the histopathologic features that are similar to Castleman's disease (CD) in SLE patients. In this report, we describe the clinicopathologic findings of CD-like peripheral lymphadenopathy, which was identified in five (26%) of 19 SLE patients. These five patients were all female with an age range of 24 to 44 years, and four of them presented with multicentric lymphadenopathy. They also had systemic symptoms and abnormal laboratory findings, indicating active disease, although two patients had not fulfilled the diagnostic criteria of SLE at the initial disease. The size of the enlarged lymph nodes seldom exceeded 2.0 cm in diameter, and biopsies revealed histopathologic features similar to CD, of intermediate type in three patients and hyaline vascular type in two according to the classification of Flendrig [7]. Immunohistochemical studies demonstrated polyclonal plasma cell populations in all five cases. Epstein-Barr virus genomes were detected in the small lymphocytes of two of the three cases examined by in situ hybridization studies. Recently, the histopathologic findings of CD have been associated with a disrupted immune response, and the present data suggest that SLE should be listed as one of the diseases showing the histopathologic features similar to CD.

Angiofollicular lymph node hyperplasia (Castleman's disease)

This review provides a comprehensive assessment of angiofollicular lymph node hyperplasia (ALNH) or Castleman's disease including pathogenesis, clinical presentation, histomorphologic and immunophenotypic findings, laboratory results, treatment, and prognosis. A division of ALNH into clinically relevant subtypes provides a framework for the consideration of the disorder. A comprehensive search of the medical literature involving ALNH using Medline was performed. Reports judged to be significant for the understanding of the disorder were analyzed and their findings incorporated into this review. ALNH is divided into localized/unicentric ALNH and generalized/multicentric ALNH due to the profound clinical differences seen between these variants. Localized/unicentric ALNH is separated by clinical and histomorphologic criteria into hyaline-vascular (HV) and plasma-cell (PC) subtypes. Generalized/multicentric ALNH may be divided by clinical criteria into generalized/multicentric ALNH without neuropathy (non-neuropathic) and generalized/multicentric ALNH with neuropathy (POEMS-associated or neuropathic). The dichotomy between these two subtypes is not absolute, with considerable clinical overlap occurring among patients presenting with generalized disease. Immunophenotypic and molecular probe studies demonstrate clonal B-cell lymphocyte populations in some cases, particularly those with generalized/multicentric ALNH. However, the finding of clonal populations is of no value in predicting malignant clinical progression. We conclude that using this division of ALNH, patients presenting with symptoms and histomorphology consistent with ALNH can be subdivided into the appropriate category of ALNH. Localized or unicentric disease, either HV or PC subtype, has an excellent prognosis with surgery being curative in the majority of cases. Generalized or multicentric disease indicates a poor prognosis with short survival, with the neuropathic variant possessing resistance to steroids and chemotherapy and a corresponding worse prognosis.

Multicentric angiofollicular lymph node hyperplasia and associated carcinoma

There is a well described association between multicentric angiofollicular hyperplasia and non-Hodgkin's lymphoma and/or Kaposi's sarcoma. Two cases of multifocal angiofollicular hyperplasia and associated carcinomas and non-Hodgkin's lymphoma are reported. We suggest that underlying immunological defects in patients with multicentric angiofollicular hyperplasia make them susceptible to the development of carcinomas, as well as non-Hodgkin's lymphoma and Kaposi's sarcoma.

Reversible plane xanthoma, vasculitis, and peliosis hepatis in giant lymph node hyperplasia (Castleman's disease): a case report and review of the cutaneous manifestations of giant lymph node hyperplasia

A patient is described who had generalized plane xanthomas, cutaneous vasculitis, peliosis hepatis, and intraabdominal giant lymph node hyperplasia of the plasma cell type. After excision of the abdominal mass, the xanthomas resolved and the liver returned to its normal size, but the patient continued to develop skin lesions. A review is presented of the cutaneous manifestations of giant lymph node hyperplasia.

Giant lymph node hyperplasia (Castleman's disease): a clinical study of eight patients

We report on 8 patients with giant lymph node hyperplasia (GLNH), diagnosed over a 10-year period. The age of the patients at diagnosis, the clinical presentation and the histological subtype varied, indicating that GNLH is a heterogeneous condition. One case was associated with liver cirrhosis, and in another patient bacterial endocarditis was diagnosed post mortem. Our study shows that GLNH is localized and benign in the young, and diffuse and aggressive in the elderly. It is concluded that GLNH should be separated into 3 clinical entities--namely, localized, systemic and reactive GLNH--defined by their clinical presentation and course, and correlated or not correlated with the histological findings.

Multicentric Castleman's disease in association with a solitary plasmacytoma: a case report

Multicentric Castleman's disease with aggressive systemic symptomatology is usually associated with the plasma cell variant. We report a case in which the clinical presentation was typical of multicentric Castleman's disease but which was associated with the hyaline vascular subtype histologically. Plasma cells were absent from all biopsies until, at autopsy, a solitary plasmacytoma was found in the vertebral column. This case supports the view that plasma cells are of primary importance in the clinical and pathological manifestations of multicentric Castleman's disease.

Multicentric angiofollicular lymph node hyperplasia associated with a solitary osteolytic costal IgG lambda myeloma. POEMS syndrome in a South American (Paraguayan) patient

We report the case of a 46-year-old woman presenting with a disorder characterized by the association of multicentric Castleman's disease, organomegaly, a solitary IgA lambda myeloma with lytic bone lesions but no serum monoclonal peak, peripheral neuropathy and skin changes. This unusual association resulted in an incomplete form of that peculiar multisystem syndrome described under a variety of names: Crow-Fukase syndrome, Shimpo's syndrome, Takatsuki's syndrome, PEP syndrome or POEMS syndrome. The possible relationship between localized and multicentric Castleman's disease with myeloma or extramedullary plasmacytoma on one hand and on the other hand with polyneuropathy and the other symptoms of the POEMS syndrome is discussed.

An immunohistological and genotypic study of the plasma cell form of Castleman's disease

The plasma cell variant of Castleman's disease (angiofollicular hyperplasia) is an uncommon and poorly understood lymphoproliferative disorder which may be associated with a wide variety of systemic features. The clinical, pathological, immunophenotypic and genotypic features of a series of five cases are presented. The clinical manifestations were variable but systemic features were present in four cases. Histologically, all five cases were similar. The characteristic follicle-like structures are composed of concentric rings of B-lymphocytes with a mantle zone phenotype, surrounding an inner core of dendritic reticulum cells. The central regions are composed of plump cells that express Factor VIII related antigen, stain with Ulex europaeus I and are associated with laminin immunoreactivity. Many of these cells stain with Ki67 indicating cellular proliferation. Between these 'follicles', plasma cells are present interspersed between high endothelial venules. Using immunohistochemical techniques two cases were polyclonal, whilst in two others unequivocal lambda/IgA restriction was present; in the other case an intermediate picture of lambda/IgA predominance was apparent. Genotypic studies in three cases indicated immunoglobulin gene rearrangements but germ line T-cell receptor genes. The significance of the apparent clonal proliferation of plasma cells is discussed and a unifying model of Castleman's disease is proposed.

Monoclonality and polyclonality of plasma cells in Castleman's disease of the plasma cell variant

Castleman's disease of the plasma cell variant observed in 21 patients was investigated morphologically and by immunohistochemistry. The male to female ratio was 2.5:1. The age ranged from 18 to 71 years (mean age 47.6 years). Histologically, the lesions were characterized by numerous, evenly distributed germinal centres ranging from large hyperplastic to small hyaline-vascular types with moderate to extensive sheets of plasma cells in between. In all cases with generalized lymph node enlargement dilated sinuses could be found. Immunohistochemical studies demonstrated a polyclonal plasma cell population in 11 of 18 lesions. Seven lesions contained a monoclonal plasma cell population, five with IgG/lambda and two with IgA/lambda; clinically, two of these patients had generalized lymphadenopathy; in none could manifestation of a plasmacytoma be found outside the lymph node lesion; only two of the seven patients exhibited a paraproteinaemia (IgG/lambda and IgA/lambda, respectively) corresponding to the Ig type of the proliferated plasma cells. Six patients with polyclonal lesions had constitutional symptoms such as fever, anaemia, polyclonal hypergammaglobulinaemia; one of these six patients manifested symptoms consistent with a diagnosis of Takatsuki syndrome. The monoclonal plasma cell type of Castleman's disease did not progress to a generalized disease. This monoclonal variant may be a lymph nodebased type of benign monoclonal gammopathy.

A benign course of multicentric Castleman's disease with involvement of the spleen and bone marrow

The multicentric variant of Castleman's disease (MCCD) is associated with a rapidly progressive and fatal course. The case described herein manifested unique clinical and histological features. Initial presentation as isolated splenomegaly was subsequently followed by widespread organ involvement, including lymph nodes and bone marrow. In spite of this, the patient had a very benign course of her disease. The case serves to expand even further the already wide clinical spectrum of Castleman's disease.

Multicentric giant lymph node hyperplasia. A report of seven cases

Multicentric giant lymph node hyperplasia (MGLH) is a distinct lymphoproliferative disorder, which may terminate in malignant lymphoma. The clinical features and laboratory findings of seven cases are reported here. The histologic changes in lymph nodes were those of giant lymph node hyperplasia, plasma cell type. Immunoperoxidase staining showed intracytoplasmatic polyclonal immunoglobulins. Malignant lymphoma supervened in two cases, one of which was proved by autopsy; in the other there was transformation of a polyclonal gammopathy into a monoclonal one. Two of the patients also developed Kaposi's sarcoma.

Angiofollicular lymphoid hyperplasia in a pulmonary fissure

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Giant lymph node hyperplasia with osteoblastic bone lesions and the POEMS (Takatsuki's) syndrome

A 38-year-old black man with giant lymph node hyperplasia (GLH), osteoblastic lesions, and the POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, M protein, skin changes) was treated at the University of Chicago Hospitals. The patient had hepatosplenomegaly and generalized peripheral lymphadenopathy. Endocrinologic abnormalities included decreased testosterone with elevated luteinizing hormone and follicle-stimulating hormone, as well as hyperprolactinemia and possible hypothyroidism. Biopsy of a right femoral lymph node revealed GLH, and an osteoblastic pelvic lesion showed a marked lymphoplasmacytic infiltrate. By immunohistochemical techniques, plasma cells in the lymph node and osteoblastic lesion were polyclonal. A polyclonal hypergammaglobulinemia was present. The lymph node T-lymphocyte population showed a decreased helper-to-suppressor cell ratio. Other findings included thickening of the skin, finger clubbing, and anasarca. A severe sensory-motor polyneuropathy was the major factor contributing to the patient's death. The association of GLH, osteoblastic bone lesions, and the POEMS syndrome has been noted previously in Japan; however, the authors are unaware of reports on Western patients who had this combination of clinical and laboratory findings.

Multicentric angiofollicular lymph node hyperplasia: a clinicopathologic study of 16 cases

A clinicopathologic analysis of 16 cases of multicentric angiofollicular lymph node hyperplasia (MAFH) was performed. Histologically, the disease was characterized by recognizable lymph node architecture that was at least partially intact, by paracortical hyperplasia with prominent vascular proliferation, and by numerous evenly distributed, apparently benign germinal centers of various types, usually including some typical hyaline-vascular centers. At the onset of the disease, 12 patients had the plasma cell (PC) type of MAFH, three patients had the hyaline-vascular (HV) type, and one patient presented with PC and HV types at separate sites. Transitions between the PC and HV types were observed in two cases. Immunologic studies demonstrated polyclonal populations of plasma cells in the lymph nodes of all patients and the absence of suppressor T lymphocytes in the one patient tested. Clinically, the patients had constitutional symptoms, multicentric lymphadenopathy, hepatosplenomegaly in many cases, and abnormal laboratory findings, including anemia, polyclonal hypergammaglobulinemia, and bone marrow plasmacytosis. The 16 patients were placed in four different clinical groups based on presentation and course: stable disease, chronic relapsing disease, aggressive disease, and development of malignant lymphoma. Ten of the 16 patients died (median survival, 26 months; range, eight to 170 months). Multicentric angiofollicular lymph node hyperplasia appears to be a variant of classic angiofollicular lymph node hyperplasia (Castleman's disease) and is associated with significant morbidity and mortality.