Chronic Lymphocytic Leukaemia as an Immunoproliferative Disorder

Lymphocytopenia preceding chronic lymphocytic leukemia

In 11 patients with an average peripheral blood lymphocyte count of 21.1 x 109/l at the time of diagnosis of chronic lymphocytic leukemia (CLL), WBC and differential counts had been recorded on 1-26 occasions more than 5 years before the diagnosis. The median lymphocyte count in the preleukemic period was 1.3 x 109/l found in a sex- and age-matched control series. In 3 patients lymphocytopenia coexisted with normal levels of serum immunoglobulins in the preleukemic period. It is suggested that the preleukemic lymphocytopenia was mainly due to low numbers of T-cell and that a deficiency in T-lymphocytes may favour the development of the malignant, monoclonal B-cell proliferation characteristic of CLL.

Hypercalcaemia associated with chronic lymphocytic leukaemia in a Giant Schnauzer

A 7-year-old male Giant Schnauzer was referred with a history of severe vomiting, lethargy, weight loss, polydipsia and polyuria. Detailed investigations revealed leucocytosis with a marked lymphocytosis, mild non-regenerative anaemia, thrombocytopenia, hypercalcaemia and azotaemia. Circulating lymphocytes were small and well-differentiated, and the same lymphoid population was present in bone marrow. Chronic lymphocyctic leukaemia with associated paraneoplastic hypercalcaemia was diagnosed. Immunohistochemical staining of a bone marrow biopsy revealed a neoplastic B-cell line expressing CD79. The dog responded to therapy with prednisolone and chlorambucil for a period of 8 months.

Morphological and immunophenotypical characterization of Japanese B-cell lymphocytic leukemia

We have analyzed the clinical and laboratory features of 42 patients with B-cell leukemia. Based on the FAB criteria, the cases were classified in 3 groups: I) typical CLL 15, II) atypical CLL 9 which included 6 cases with large cells, and III) B-cell lymphoma in leukemic phase 18. Cases diagnosed as typical CLL (group I) had similar features to those seen in CLL patients from Western countries. The morphology and markers in cases from group III corresponded to B-cell lymphoma in leukemic phase. On the other hand, group II included 3 cases classified as atypical CLL according to FAB criteria. 1 CLL/PL and 2 mixed CLL and 6 cases with rather distinct features, namely: 1) lymphocytosis (42 +/- 41 x 10(9)/l in average) with large mature-looking lymphocytes with abundant cytoplasm: 2) an immunological profile consistent with CLL but, in addition with the consistent expression of CD38; 3) absence of a monoclonal band in the serum and 4) a clinical course and prognosis similar to CLL. Our findings suggest the existence of a B-cell disorder in Japan very close to CLL but distinct from typical and atypical CLL as seen in Western countries. Further studies would clarify whether such an entity is exclusively confined to Japan having a distinct natural history.

Persistent polyclonal B-cell lymphocytosis

We document a case of persistent lymphocytosis in which the characteristic binucleated circulating lymphocytes were shown immunologically to be polyclonal B-cells. Cytogenetic and molecular studies failed to show a clonal population. A review of the literature on this rare condition, persistent polyclonal B-cell lymphocytosis, highlights an association with the female sex, HLA-DR7 antigen, smoking and raised levels of IgM, all of which were present in our patient.

A simple technique for the determination of kappa and lambda immunoglobulin light chain expression by B cells in whole blood

This article describes the development of a simple technique by which the numbers of surface immunoglobulin expressing cells can be analysed by dual fluorescence flow cytometry in samples of whole blood. We have compared the results obtained using this procedure with those obtained using samples prepared by traditional density gradient centrifugation, and demonstrate an excellent correlation between the two techniques. The method is applicable both to blood samples from normal individuals and from patients with B cell malignancies such as B-CLL and B-NHL. We have also confirmed previous findings that density gradient centrifugation may preferentially deplete certain lymphocyte subsets. This technique offers the following advantages: (i) it is rapid, (ii) it is accurate, (iii) it is reliable, (iv) it is useful in cases of lymphopenia, and (v) it requires only a small volume of blood. It is likely to be applicable to other situations in which the presence of serum factors interfere with antibody staining in whole blood.

Prolymphocytic transformation of chronic lymphocytic leukemia. A report of three cases and review of the literature

Three cases of prolymphocytic transformation of chronic lymphocytic leukemia (PLL-trs CLL) are described, and a review of the literature yields 15 additional cases. PLL-trs CLL may be recognized when two populations of cells are present and the number of prolymphocytes are greater than 15% admixed with the small round lymphocytes of CLL. Surface immunoglobulin intensity appears to be greater on the prolymphocytes than on the small lymphocyte in the same case, suggesting a clonal differentiation. At the time of transformation, the spleen is generally larger than at the time of diagnosis of CLL, and lymphadenopathy is variable. Transformation is thought to be associated with increasing refractoriness to treatment and shorter survival, although most of the deaths occurred in clinical Stages III and IV, known to have a poor prognosis. Similar features between PLL-trs CLL and so-called de novo PLL also suggest an evolutionary process. However, additional morphologic and immunologic studies in transforming CLL cases are necessary to answer this question.

Coexistence of chronic myelogenous leukemia and chronic lymphocytic leukemia

A 55-year-old man is reported who initially developed chronic lymphocytic leukemia. Seven years later, after chemotherapy with chlorambucil, chronic myelogenous leukemia was diagnosed in addition to the chronic lymphocytic leukemia. Four previously reported cases with the same sequence of events are reviewed as well as cases of chronic myelogenous leukemia following chemotherapy alone.

Reactivity of the monoclonal antibody RFB1 in chronic B-cell leukaemias

The monoclonal antibody RFB1, which reacts with early haemopoietic precursors in human bone marrow and peripheral T-lymphocytes, but not with pre-B cells and mature peripheral blood and marrow B lymphocytes, was tested in blood from 60 patients with chronic B cell leukaemias. All 37 cases of B chronic lymphocytic leukaemia (B-CLL) and 9 of hairy cell leukaemia (HCL) were positive. The antibody showed particularly strong reaction in HCL. On the other hand, RFB1 did not react with peripheral blood and B lymphocytes from 9 patients with non-Hodgkin lymphoma (NHL) in leukaemic phase and was negative or weakly expressed in 5 with prolymphocytic leukaemia (B-PLL). These findings may be significant for investigations on the cell origin of B-CLL and HCL. The reactivity of RFB1 was different from that of two anti-T1 monoclonal antibodies. The combined use of these reagents gave distinct patterns in B-CLL (RFB1+, T1+), HCL (RFB1++, T1-) and NHL and B-PLL (RFB1-/+/-, Tl-/+), suggesting they may be of value in the differential diagnosis of these B-lymphoproliferative disorders.

Cytochemistry of normal lymphocyte subsets defined by monoclonal antibodies and immunocolloidal gold

The cytochemical reactivities of 3 acid hydrolases, alpha-naphthyl acetate esterase (ANAE), acid phosphatase and beta-glucuronidase were investigated in normal peripheral blood lymphocyte subsets defined by monoclonal antibodies OKT3, 4, 8 and FMC4 (anti-Ia). A combined monoclonal antibody-immunocolloidal gold/cytochemical staining procedure was used to determine enzyme activities and distributions of reaction product in each subset. Cytochemical profiles for each lymphocyte subset were defined. The majority (greater than 85%) of T cells (OKT3+) were positive for all 3 enzymes whereas a minority (less than 40%) of B cells (FMC4+) displayed reactivity. The cytochemical profiles of T helper/inducer (OKT4+) and T suppressor/cytotoxic (OKT8+) cells were not significantly different and corresponded to that observed for OKT3+ cells; thus none of these enzymes can be used to distinguish normal lymphocyte subsets cytochemically. ANAE reactions were further analysed, in the respective subsets, on the basis of dot-like or scattered/diffuse reactivity. The ratios of cells displaying dot-like: scattered/diffuse reactivity, in the respective subsets, were OKT3+, 5.4:1; OKT4+, 8.1:1; OKT8+, 2.4:1; FMC4+, 0.4:1. The cytochemical profiles and ANAE reactivities of T cell subsets identified by monoclonal antibodies differ from those displayed by T cell subsets defined by Fc receptors and confirms that there is little correlation between subsets defined by these two methods.

Nuclear clefts in chronic lymphocytic leukaemia. A light microscopic and ultrastructural study of a new prognostic parameter

Peripheral blood lymphocytes from 48 consecutive, newly diagnosed CLL patients were examined by light- and electron-microscopy for the presence of nuclear cleaving or folding. On this basis, the patients could be subdivided into 2 easily separable morphological groups. In 42 patients the lymphocytes had regular round nuclei. In 6 patients (13%) the lymphocytes of peripheral blood had a highly irregular nuclear outline characterized by pronounced cleaving or folding of the nuclear membrane. In 4 of these 6 patients immunological investigations demonstrated membrane markers consistent with B-cell monoclonality. Age, sex, distribution between stages as well as mode of clinical presentation were all alike in the 2 groups of patients. In spite of this a statistically significant, highly increased mortality was observed in patients with lymphocyte nuclear irregularities. Thus, 50% of all deaths occurred in this small group of patients. These findings indicate that lymphocyte nuclear cleaving or folding represents a stage-independent prognostic parameter, which permits selection of a small but easily identified high-risk group of patients.

Chronic lymphocytic leukemia: a monoclonal disease

A black woman with chronic lymphocytic leukemia (CLL) was found to have monoclonal B lymphocytes with one type of surface immunoglobulin and one variant of G6PD (glucose-6-phosphate dehydrogenase) (G6PD A). Erythrocytes and T cells contained both G6PD A and G6PD B and hence were of polyclonal origin. The CLL cells in this patient likely arose from a developmental stage later than the step of differentiation into T and B lymphocytes. Furthermore, her erythrocytes did not arise from a stem cell affected by the CLL process.

Interaction of Epstein-Barr virus with leukaemic B cells in vitro. II. Cell line establishment from prolymphocytic leukaemia and from Waldenström's macroglobulinaemia

Leukaemic B-cell populations were prepared from six patients with high-count prolymphocytic leukaemia (PLL) as well as from one patient with Waldenström's macroglobulinaemia (WM) in frankly leukaemic phase, and their response to in vitro Epstein-Barr (EB) virus infection was monitored in terms of expression of the virus-associated nuclear antigen EBNA and of virus-induced transformation to continuous cell lines. The individual leukaemic populations, tested on several occasions, gave reproducibly different responses one from another which were not obviously related to differences either of surface immunoglobulin phenotype or of immunoglobulin secretor status in vivo. After infection, four out of six PLL populations showed either transient or a more persistent expression of EBNA, always involving a minority of the cells, with no evidence of any virus-induced transformation up to six weeks. In contrast, two out of six PLL samples as well as the WM sample rapidly gave rise to EBNA-positive cell lines which, on the evidence both of restricted immunoglobulin class expression and of abnormal marker chromosomes, were clearly derived from the leukaemic cells. Further comparative studies of such leukaemic B-cell populations may help to define host cell components necessary for the triggering of EB-virus-induced cellular transformation.

Hairy-cell leukaemia: an immunoperoxidase study of paraffin-embedded tissues

Paraffin sections of a variety of tissues from 12 patients with typical hairy-cell leukaemia (HCL) were stained for immunoglobulin heavy and light chains by the peroxidase-antiperoxidase (PAP) technique. Plasma cells were frequent, particularly in a lymph node from a severely infected patient. The reactive nature of the plasma cells of HCL was suggested by the fact that there was no restriction of light-chain expression, although viable hairy cells were shown to express monoclonal surface immunoglobulin. This, together with the absence by both light and electron microscopy of forms intermediate between hairy cells and plasma cells and the lack of ribosome-lamella complexes in the plasma cells, suggested that hairy cells do not differentiate into plasma cells. Although hairy cells are known to contain immunoglobulin, this was not demonstrable in hairy cells in the paraffin-embedded tissue. The PAP technique was also useful for demonstrating abundant splenic macrophages in HCL.

Chronic lymphocytic leukemia in association with a second lymphoproliferative disorder: response to chemotherapy in two cases

The development of either histiocytic lymphoma or Hodgkin disease in association with pre-existing chronic lymphocytic leukemia has been described in the literature as a terminal event. We describe two patients in whom the diagnosis of a second malignant lymphoma was made during life and who achieved objective clinical response after a change in therapy to a more aggressive combination of drugs. We conclude that patients with chronic lymphocytic leukemia who have had a sudden change in their clinical course should have thorough reevaluation, looking specifically for the development of a second lymphoproliferative disorder. If this is discovered, more aggressive therapy should be initiated.

Identification of the hairy cells of leukaemic reticuloendotheliosis by an esterase method

A distinctive pattern of alpha-naphthyl butyrate esterase positivity was observed in all of a series of 14 patients with HCL. This pattern was not observed in a range of other haematological malignancies including nine cases of CLL, two cases of Sézary's syndrome, six cases of null cell ALL, two cases of Schilling-type monocytic leukaemia and one case of lymphosarcoma cell leukaemia. The potential diagnostic value of this simple cytochemical test is discussed in relation to existing methods.