T-cell lymphomas. A cell origin-related classification on the basis of cytologic, immunologic, and enzyme cytochemical criteria

Clinicopathologic study of 212 cases of peripheral T-cell lymphoma among the Japanese

BACKGROUND

Postthymic/peripheral T-cell malignancy shows significant histopathologic and clinical diversity, even in its prognosis, and the correlations remain to be debated.

METHODS

The clinicopathologic features of 212 Japanese patients with these neoplasms were investigated.

RESULTS

There were 131 male and 81 female patients, whose ages ranged from 2 to 90 years (mean, 51.7 years). Lymphadenopathy was the most frequent clinical presentation, and the patients also had frequent skin lesions, hyperimmunoglobulinemia, hypercalcemia, and a rapid clinical course. Furthermore, the differences in the histologic features of each subcategory reflected the clinical pictures. The immunophenotypic analysis was indispensable in establishing a correct diagnosis, and the high-grade tumors often showed loss of pan-T antigens.

CONCLUSIONS

The histopathologic classification proposed by Suchi et al., which has been incorporated into the updated Kiel classification, showed a good prognostic correlation.

A clinicopathologic study of node-based, low-grade, peripheral T-cell lymphoma. Angioimmunoblastic lymphoma, T-zone lymphoma, and lymphoepithelioid lymphoma

Postthymic (peripheral) T-cell malignancy shows marked diversity in histopathologic appearances as well as in clinical and prognostic aspects. Histologic findings and clinical behavior of 110 cases of the three specific types of low-grade, peripheral T-cell lymphomas, i.e., lymphoepithelioid (LeL), angioimmunoblastic (AILD), and T-zone (TzL) lymphomas, were studied. There were 74 men and 36 women (age range, 24 to 90 years; median, 58). Histologic study of LeL, AILD, and TzL showed prominent reactive features which are distinct from those of high-grade, T-cell lymphomas (pleomorphic/immunoblastic types). Corresponding to the differences in the histologic pictures of each type, there were differences in the clinical pictures and prognosis. Hypergammablobulinemia (greater than 4 g/dl) was more common in AILD than in the others. However, these three types exhibited a widely variegated, sometimes overlapping spectrum of histologic appearances, and it was extremely difficult to distinguish one from the other on several occasions. The same was true of their clinical and laboratory findings, and they had a relatively favorable prognosis as compared with pleomorphic/immunoblastic lymphomas. Although the conventional phenotypic analysis showed the prominent mixture of helper/inducer and cytotoxic/suppressor T-cells with a varying degree of B-cells and histiocytes, the double immunohistochemical study revealed that the neoplastic cells consisted predominantly of helper/inducer cells. Furthermore, five cases (5%) showed the morphologic transition among the three types or development into pleomorphic/immunoblastic lymphoma. They seemed to constitute a comprehensive and yet distinct group of T-cell lymphomas. Based on morphologic findings and clinical data, the authors demonstrated the distinct character of the node-based, low-grade, T-cell lymphomas and also the relationship among the three types in this group. The results of phenotypic and genotypic analyses also support the concept proposed here.

Peripheral T-cell lymphomas: an evaluation of reproducibility of the updated Kiel classification

Haematoxylin and eosin, and Giemsa stained sections from 100 peripheral T-cell lymphomas were examined blind on two occasions by four experienced haematopathologists in order to evaluate the inter- and intra-observer reproducibility of the updated Kiel classification for these malignancies. In all cases, the T-cell phenotype had been established previously in frozen section using a panel of monoclonal antibodies. Analysis by kappa statistics showed poor reproducibility, both overall and for most subtypes, with the exception of large cell anaplastic lymphoma. The distinction between low- and high-grade lymphomas was also unsatisfactory. These results indicate the need for improved precision in the definition of histological categories of peripheral T-cell lymphoma. The reproducibility of the update Kiel classification for peripheral T-cell lymphomas in its present form is inadequate.

Imprint cytology of non-Hodgkin's lymphomas based on a study of 212 immunologically characterized cases: correlation of touch imprints with tissue sections

The classification of non-Hodgkin's lymphomas (NHLs) has been traditionally based on analysis of histologic sections and has been supplemented more recently by immunologic marker studies. It was the purpose of the present study to illustrate, side-by-side, sections and Romanowsky-stained imprints from the same surgical specimen from practically all categories of immunophenotyped NHLs, including rare and atypical variants that were difficult to classify from the histologic sections alone. Our results indicate that imprint cytology may reveal nuclear and cytoplasmic details not discernible in even the best tissue sections and that it may be selectively helpful in contributing to the classification of NHLs. Our results also show that the relative value of imprint cytology in the classification of malignant lymphomas varies greatly among categories. Specifically, we have found that imprints assist in three ways: the recognition of plasmacytoid features in small cell lymphocytic lymphomas, the recognition of plasmacytoid immunoblastic lymphoma, and the differentiation between NHLs which may be difficult to distinguish histologically. These include (1) small lymphocytic lymphoma versus lymphocytic lymphoma of intermediate differentiation, (2) true histiocytic malignancies versus large cell malignant lymphomas with abundant cytoplasm and/or phagocytosis, (3) anaplastic myeloma versus plasmacytoid immunoblastic lymphoma, (4) large noncleaved versus plasmacytoid immunoblastic lymphoma, (5) lymphoblastic lymphoma versus diffuse small cleaved cell lymphoma, and (6) lymphoblastic lymphoma versus small noncleaved cell lymphoma. Lymph node imprints are easy to prepare and readily interpretable by those experienced in the study of abnormal blood and bone marrow films. Their value as an ancillary methodology aimed at optimal accuracy in the classification of NHLs should be recognized.

Peripheral T-cell lymphomas. Immunologic and enzyme histochemical analysis of 15 cases

Fifteen cases of peripheral T-cell lymphoma were studied to evaluate the respective properties of various histologic types using enzyme histochemical and ultrastructural examinations in addition to immunological methods. Eleven cases in an ATLA-negative group manifested various histologic patterns such as IBL-like, pleomorphic and Lennert's lymphomas in comparison with the relatively monomorphic proliferation of neoplastic lymphoid cells in the 4 ATLA-positive cases. The presence of neoplastic clear cells is characteristic of peripheral T-cell malignancies, and is likely to be found in CD4+ lymphomas. There is an occasional reaction of epithelioid histiocytes and plasma cells with eosinophils, the former being designated Lennert's lymphoma and the latter IBL-like T-cell lymphoma. Immunological examination revealed four immunophenotypic patterns: (1) CD2+3+4+8-, (2) CD2+3-4+8-, (3) CD2+3+4-8+, and (4) CD2+3+4+8+, but did not provide information concerning the intimate relationship between histologic types and immuno-phenotypes. beta-Glucuronidase reactivity, however, contributed to the distinction between helper and suppressor T-cell malignancies, suggesting its usefulness for distinguishing these two cell types and their malignant counterparts.

Primary gastric peripheral T-cell malignant lymphoma with helper/inducer phenotype. First case report with a complete histological ultrastructural and immunochemical study

Primary gastrointestinal T-cell malignant lymphomas (T-ML) are very rare. In this case report we describe a primary gastric tumor with local lymph node involvement. On the basis of histologic, immunohistochemical, and electron microscopic studies, the authors classified this tumor as a pleomorphic T-ML, large cell variant with peripheral helper/inducer T-cell phenotype (Leu1/CD5+, Leu4/CD3+, Leu5/CD2+, Leu9/CD7+, and Leu3/CD4+). The extreme pleomorphism of lymphoma cells, the numerous giant cells, and the presence of tumor nodules with two or three concentric layers were the three striking morphologic features of our case. Tumor cells showed an inconstant but true positive staining with anti-LeuM1/CD15 and LeuM3/CD14 antibodies. Vimentin positivity could be related to the presence of intermediate filaments at ultrastructural level. Neuron-specific enolase reactivity was a peculiar but unexplained feature. Furthermore, the positivity of the surface markers Ki-1/CD30, anti-Tac/CD25 and HLA-DR, and the nuclear marker Ki-67 suggested an activation state and a high proliferative activity of the tumor cells. This study emphasizes the usefulness of combined pathologic methods in order to rule other diagnoses such as undifferentiated carcinoma, malignant melanoma, malignant histiocytosis, B-cell lymphoma and interdigitating reticulum cells sarcoma, in view of an extremely polymorph tumor proliferation. This is apparently the first completely documented case report of a primary gastric pleomorphic T-ML of peripheral T-cell origin.

Histopathology and immunohistochemistry of peripheral T cell lymphomas: a proposal for their classification

Based on the results of histological and immunohistochemical observations of a large number of peripheral T cell lymphomas from China, England, Germany and Japan, histological and cytological morphology were correlated with immunophenotype, aetiological association with HTLV-1, and clinical behaviour to produce a working classification of the T cell lymphomas. This classification, based mainly on cytological criteria, divides the peripheral T cell lymphomas into tumours of low grade and high grade malignancy. Adult T cell lymphoma/leukaemia (ATLL) is caused by HTLV-1 and belongs chiefly to the high grade category. Some tumours are characterised by an admixture of other cells (epithelioid cells, follicular dendritic cells, etc) and structures (high endothelial venules, follicles), which may indicate the secretion of lymphokines by the tumour cells. Clear cells seem to be specific for T cell lymphomas and may occur in various types of peripheral T cell lymphoma.

Peripheral T-cell lymphomas: a clinicopathological and immunological study of 10 cases

Diagnosis and classification of T-cell lymphomas is notoriously difficult. Existing classification schemes are insufficient. Some clinicopathologically well defined T-cell lymphomas exist (mycosis fungoides, Sézary's syndrome, and T-lymphoblastic lymphomas) but the remaining tumours, frequently called peripheral T-cell lymphomas, are a heterogeneous group, clinically, morphologically and immunologically. The data on 10 peripheral T-cell lymphomas are presented and compared to data from the literature. Patients were elderly, had a high frequency of extranodal localizations (notably the skin 75%) and had a poor prognosis: five of 10 patients have died, median survival 22 months. Morphologically and immunophenotypically the group is very heterogeneous. The variety of blast cell morphology is emphasized. No correlations were found between immunophenotype and prognosis, or immunophenotype and morphology.

Immunoblastic sarcoma of T- and B-cell types: morphologic description and comparison

Immunoblastic sarcoma (IBS) is a large cell lymphoma conceptually related to transformed T and B lymphocytes of the extrafollicular compartment of the immune system (immunoblasts). This light microscopic study of a series of 47 immunologically defined cases of IBS was undertaken in an attempt to define more precisely the morphologic features of the T- and B-cell subtypes. A remarkable morphologic spectrum characterized T-IBS (31 cases), which could be divided into two main groups: 1) tumors composed of varying mixtures of small, medium-sized, and large transformed cells; and 2) tumors with more homogeneous populations of medium-sized or large transformed cells. These cells, in all sizes, generally had abundant pale-staining cytoplasm, delicate nuclear membranes, finely dispersed chromatin, and one to several, small or medium-sized, prominent nucleoli. A distinctive background of small, irregular lymphocytes was frequently present. Plasmacytoid differentiation, seen most consistently as amphophilic staining of the cytoplasm, generally characterized B-IBS (16 cases). B-IBS similarly showed a morphologic spectrum that occurred in two main forms: 1) tumors consisting of a spectrum of transformed cells, with the smaller cells often showing the most striking plasmacytoid differentiation; and 2) tumors consisting predominantly of medium-sized to large transformed cells with varying degrees of plasmacytoid differentiation. With this constellation of features, all but two cases of T-IBS and one case of B-IBS were morphologically distinguishable.

Immunoelectron microscopic studies on peripheral T-cell lymphomas using monoclonal antibodies

Ultrastructural comparison between helper/inducer and suppressor/cytotoxic type cells in peripheral T-cell lymphomas was made using the immunoperoxidase technique. The nuclei of T4 positive cells were more irregular in outline than those of T8 positive cells, and nuclear irregularity was further pronounced in the cells of the adult T-cell leukemia/lymphoma which were of helper/inducer type cells. The suppressor/cytotoxic type cells possessed in their cytoplasm scattered dense bodies encircled by distinct membranes, although they also contained clustered dense bodies. On the other hand, the helper-inducer type cells had only clustered dense bodies. No other significant differences were observed regarding other cytoplasmic organelles between T4 positive cells and T8 positive cells. The existence of the peripheral T-cell lymphomas with "double-markers" which possessed surface antigens for both helper/inducer and suppressor/cytotoxic subsets was also demonstrated.

Immunopathology of non-Hodgkin lymphomas

The immunopathological features of lymphocytic non-Hodgkin lymphomas (NHL), follicular centre cell tumours and "large-cell" NHL are described with particular emphasis on in situ evaluation of cryostat sections using monoclonal antibodies. The immunological phenotypes of tumour cells and the pattern of "reactive" cellular infiltrates with characteristic differences for the various subtypes are summarized. Immunological membrane features of the following lymphocytic NHL of B lymphocyte origin are discussed in detail: B-CLL (most common phenotype of the lymphoma cells: VIB-C5, To-15, Ia, Leu-1), lymphoplasmocytoid NHL (To-15, Ia), B-prolymphocytic leukaemia (VIB-C5, To15, Ia, Leu (+/-), FMC-7(+/-] and hairy-cell leukaemia (HCL: To-15, Ia, FMC-7). NHL of T-lymphocytes detailed in respect of mycosis fungoides and Sézary syndrome (OKT-3, OKT-4, OKT-11), to subtypes of T-CLL with particular emphasis on the "azurophilic" type, to T-zone NHL, and to adult T-cell leukaemia/lymphoma (OKT-3, OKT-4, OKT-11, anti-tac), all of them with the usual immunological phenotype of T-helper (TH) lymphocytes. NHL with a predominance of T-suppressor (TS) lymphocytes include the immunoblastic lymphadenopathy like T-cell lymphoma (OKT-3, OKT-8, OKT-11) and some lymphoepitheloid (Lennert) lymphomas. Immunological features of follicular centre cell tumours are discussed with emphasis on similarities and differences with the normal germinal centre. Tumour cells usually show the following membrane phenotype: centroblastic/centrocytic (cb/cc: To-15, VIL-Al, Ia; meshwork of non-neoplastic R4/23+, To-5 + DRC), centrocytic (VIB-C5, To-15, Leu-1, Ia; R4/23 and To-5 meshwork), centroblastic (cb, To-5, To-15, Ia, VIL-Al +/-). "Large-cell" NHL include the last entity (cb), immunoblastic (B-ib, T-ib) and lymphoblastic (lb) NHL and are discussed in respect to B-ib (Ia, To-15 +/-, VIL-Al +/-), T-lb (WT-1, OKT-6 +/-, OKT-11 +/-), pre-B-lb (VIB-C5, Ia, TdT, VIL-Al +/-) and Burkitt-type NHL (VIB-C5, VIL-Al, Ia, sIg). "Reactive" cellular infiltrates may account for a large fraction of the cellular content of NHL (e.g. the mean TH and TS content amount to about 40% of that seen in normal lymph nodes). In comparison to other NHL B-CLL and cb/cc showed the highest, HCL the lowest number of TH X TS exhibited less typical alterations.(ABSTRACT TRUNCATED AT 400 WORDS)

Epitheliotropic lymphoma of the small bowel. Report of a fatal case with cytotoxic/suppressor T-cell immunotype

The authors report the clinical, pathologic, and immunologic features of a case of jejunal cytotoxic/suppressor T-cell lymphoma associated with intractable malabsorption. Histologically, the tumor exhibited striking involvement of small bowel surface and glandular epithelium, and of epithelium in sites of disease dissemination. This epitheliotropism consisted of both cell clusters resembling Pautrier 's microabscesses and single cells within epithelium. Grossly, the jejunal mucosal fold pattern was completely obliterated by lymphoma which formed miliary nodules and multiple distinct tumor masses. Despite aggressive chemotherapy the patient developed widespread disease, and died 11 months after presentation. At autopsy, in addition to disseminated lymphoma, there was a notable activation of hematopoiesis evidenced by extensive extramedullary hematopoiesis and bone marrow hypercellularity. Many lymph nodes spared by the lymphoma showed a polyclonal proliferation of plasma cells and immunoblasts. In view of recent immunologic evidence that normal cytotoxic/suppressor T-cells selectively home to the gut surface epithelium, striking tumor cell epitheliotropism may be a morphologic marker for visceral lymphomas of cytotoxic/suppressor T-cell origin. This unique case broadens the clinical and morphologic spectrum of T-cell disorders.

Non-Hodgkin's lymphoma of the tonsil. A clinicopathologic study of 65 cases

Sixty-five patients presenting to M. D. Anderson Hospital and Tumor Institute with Stages IE and IIE primary tonsillar lymphoma between 1954 and 1981 were reviewed. All cases were non-Hodgkin's lymphomas, with the majority being diffuse large cell lymphoma (85%). Initial therapy was radiotherapy alone in 54 patients, radiotherapy combined with chemotherapy in 8 patients, and chemotherapy alone in 3 patients. Stage was the most important prognostic factor, with 86% and 41% 5-year survivals for Stages IE and IIE, respectively (P = 0.006). Lymphangiography was crucial in staging patients with clinically positive cervical lymph nodes because 94% of clinically staged IIE patients developed recurrent disease, in comparison with only 50% of lymphangiogram-staged IIE patients. The incidence of large cell lymphoma was so high as to preclude analysis of survival by histologic type. From this limited series, radiotherapy alone would appear to be sufficient initial therapy for Stage IE patients, whereas Stage IIE patients probably benefit from the addition of prophylactic chemotherapy. Relapses were most common in nonirradiated lymph-node-bearing areas, with the majority presenting in the first 2 years following initial therapy. The salvage of relapsing patients has been disappointing, with the best hope residing in combination chemotherapy.

Adult non-Hodgkin's lymphoma. Correlation of cell surface marker phenotype with prognosis, the new working formulation, and the Rappaport and Lukes-Collins histomorphologic schemes

The interrelationships between histomorphologic classification, cell surface marker phenotype and prognosis were prospectively studied in 130 adults with non-Hodgkin's lymphomas. Within each of the classification schemes used there were certain histologic variants that exhibited heterogeneity of cell lineage as well as those that were extremely uniform. Diffuse lymphomas with cell populations consisting of large cells, or mixtures of large and small cells were the most heterogeneous phenotypically and were most resistant to precise definition of immunologic cell lineage. The new Working Formulation for Clinical Usage likewise exhibited considerable heterogeneity of phenotype even within well defined histomorphologic categories. Two immunologic phenotypic variables that conferred a significant favorable prognosis were the expression of surface membrane immunoglobulin (B derivation) and the simultaneous expression of a membrane mu and delta immunoglobulin heavy chain. The results of this study suggest that cell surface marker phenotypic determinations have well defined and potentially useful correlations with histomorphologic classification schemes, and are useful in predicting biologic behavior and prognosis. It is suggested that a knowledge of both immunologic phenotype and histomorphologic characteristics is necessary in formulating therapeutic decisions.

Antibody probes in diagnosis and classification of lymphomas

The use of immunohistochemistry is discussed with respect to its role in assisting with the classification and diagnosis of lymphomas. Attention is drawn to methods of achieving optimal tissue fixation and preparation, which are necessary prerequisites for the precise cytochemical demonstration of the various lymphocyte and related cell type markers.

Malignant lymphoma, diffuse mixed small and large cell. A clinicopathologic study of 47 cases

The clinical and pathologic features of 47 cases of malignant lymphoma, diffuse mixed small and large cell (diffuse mixed lymphoma) are described. Diffuse mixed lymphomas contained approximately equal numbers of small and large cells (30-70%) and comprised 6% of all non-Hodgkin's lymphomas. They occurred in middle-aged and elderly patients (median age = 63 years), showed a female predominance, and were clinically advanced at presentation. The majority of patients exhibited prominent extranodal disease, which frequently involved multiple unrelated sites and usually occurred in conjunction with nodal disease. A notable morphologic spectrum of lymphoma was seen within this series, including 20 cases of mixed small cleaved and large cell (with cleaved and noncleaved nuclei), eight cases of mixed small lymphocytic and large cell (transformed prolymphocytes and blast-like cells), and 12 cases of mixed small cell and large cell, "immunoblastic" lymphoma (with plasmacytoid, clear cell or hyperconvoluted features). There was no significant difference in response to treatment and survival between those cases with less than 50% large cells and those with greater than 50% large cells. The poorest treatment response appeared to be in patients with mixed small cell and large cell, "immunoblastic" lymphomas. Patients with diffuse mixed lymphoma appeared to show a favorable response to cyclphosphamide, Adriamycin, vincristine, and prednisone (CHOP) and an unfavorable response to other treatment modalities.

Non-Hodgkin's lymphoma in northwestern Kyushu Island of Japan. Clinicopathological studies based on the Japanese classification of malignant lymphoma

Ninety cases of node-based non-Hodgkin's lymphoma in northwestern Kyushu, Japan were classified according to the Japanese Lymphoma Study Group (LSG) and the immunological as well as clinicopathological studies were performed. There were 6 cases of small cell type, 23 of medium-sized cell type, 25 of large cell type, 20 of pleomorphic type, 10 of lymphoblastic type and 6 cases of specific lymphomatous lesions (Lennert's lymphoma and T-cell lymphoma with angioimmunoblastic lymphadenopathy-like pattern). Immunologically, the T-cell character was predominant in pleomorphic type (100%), specific lymphomatous lesions (100%), medium-sized cell type (80%) and large cell type (60%). Clinically, leukemic manifestation was frequently encountered in all histological types except for large cell type. The leukemic cells in pleomorphic type and T-medium-sized cell type were polymorphic, similar to those of adult T-cell leukemia. Skin lesions were found chiefly in leukemic cases of pleomorphic and T-medium-sized cell types, and non-leukemic cases of T-large cell type. The worst prognosis was observed in the pleomorphic type, especially of leukemic form. These results support the proposal of pleomorphic type as a distinct entity in prospecting the immunological subtype, clinical manifestations, and survival. In addition, T-medium-sized cell and pleomorphic types, having common clinicopathological characteristics, may be categorized as one group. On the other hand, T-large cell type seems to be composed of heterogenous groups of the peripheral T-cell tumor, although some cases overlap with pleomorphic type.