Malignant lymphoma. 1

Diagnostic pitfalls of discriminating lymphoma-associated effusions

High serum lactate dehydrogenase (LDH) level, immunologic defects, enlarged mediastinal lymph nodes, and frequent hydration and diuresis in lymphoma patients may affect the development of pleural effusion (PE). The study was to assess the clinical utility of "Light criteria" and the "recommended algorithm for investigating PEs" in patients with lymphoma.The characteristics of 126 PEs of lymphoma patients who underwent diagnostic thoracentesis between January 1, 2003, and April 30, 2012, were reviewed. Using Light criteria, 29 (23%) PEs were incorrectly classified. The sensitivity for exudates in Light criteria was 88% and the specificity was only 44%. In 32 transudates, PE LDH correlated with blood LDH concentration (P < 0.001, r = 0.66). Nine transudates were misclassified as exudates (50%; 9/18) just due to PE LDH more than two-thirds the upper limits. Among the 56 bilateral PEs, 33 (59%) were exudates. Ten (63%) polymorphonuclear (PMN)-predominant exudative PEs were malignant. Infective PEs were often mononuclear (67%) rather than PMN predominant.When a patient has lymphoma with either unilateral or bilateral PE, thoracentesis for microbiological testing and cytology is imperative. Carefully clinical correlation in addition to the result from Light criteria and differential cell count is essential for prompt management.

Adenosine deaminase activity in pleural effusions of lymphoma patients

BACKGROUND AND AIM

The purpose of this study was to assess the relationship of pleural adenosine deaminase (P-ADA) and non-Hodgkin's lymphoma (NHL).

DESIGN AND METHODS

We retrospectively analysed 63 NHL patients with pleural effusions who accepted a diagnostic thoracentesis and who had P-ADA available at the China Medical University Hospital (Taichung, Taiwan) between January 2003 and April 2012.

RESULTS

There were 46 exudates [40 malignant pleural effusions (MPE), 5 complicated para-pneumonic effusions and 1 undiagnosed effusion] and 17 transudates. The P-ADA activity was significantly different between the two groups (P < 0.005). Among 40 MPE cases, 29 were due to B-cell and 11 due to T-cell NHL. There was no pleural transudative effusion with P-ADA value higher than 26 U/l in our study, but simultaneously 48% (22/46) of exudative pleural effusions showed a P-ADA value under that cut-off point. The P-ADA level reached the diagnostic cut-off for tuberculosis (40 IU/l) in 11 cases of MPE (11/40 = 27.5%): 9 B-cell NHL (9/29 = 31%) and 2 T-cell NHL (2/11 = 18%). The median levels (25th, 75th percentiles) of P-ADA were 28 IU/l (14-50) in the MPE of B-cell NHL and 26 IU/l (14-28) in the T-cell NHL (P = 0.693).

CONCLUSIONS

The use of P-ADA in NHL effusion could aid the separation of transudates from exudates. Around one-quarter MPE of NHL had abnormal P-ADA ( > 40 IU/l). There was no difference in the P-ADA activity in T-cell and B-cell NHL.

Infections in patients with leukemia and lymphoma

Infectious complications remain a significant issue in the care of patients with hematologic malignancies. Inherent immune defects related to the primary disease process are present in patients with disorders such as chronic lymphocytic leukemia, multiple myeloma, hairy cell leukemia, and Hodgkin lymphoma. Therapy-related immunosuppression is also commonplace in these patients. This includes not only treatment-related neutropenia, but also defects in cell-mediated immunity, such as those that occur with purine analog therapy. In this chapter, we will review the pathogenesis of infection in these disorders, as well as the spectrum of infectious complications seen and suggested strategies for the prevention of infection.

Myristylation of Pr60gag of the murine AIDS-defective virus is required to induce disease and notably for the expansion of its target cells

Murine AIDS (MAIDS) is characterized by severe lymphadenopathy and splenomegaly. The proliferation of the infected target B cells is also an important manifestation of the disease (M. Huang, C. Simard, D. G. Kay, and P. Jolicoeur, J. Virol. 65:6562-6571, 1991). The etiologic agent of MAIDS is a defective murine leukemia virus that is deleted of most of its pol and env genes and appears to encode a single protein, the Gag precursor Pr60gag protein. Pr60gag is myristylated and attached to the plasma membrane. To study the role myristylation on the function of Pr60gag, we have generated a myristylation-negative (Myr-) mutant of the MAIDS defective virus. We found that Myr- Pr60gag interacted less tightly with the plasma membrane. In addition, the Myr- MAIDS defective virus mutant was unable to induce expansion of infected cells and was nonpathogenic. These results emphasize the essential role of Pr60gag in the disease process. Our data also suggest that Pr60gag, once recruited to the cell membrane through its myristylation, interacts with other membrane-bound effectors to send signals to induce proliferation of the infected cells and to initiate immune dysfunctions.

The majority of cells infected with the defective murine AIDS virus belong to the B-cell lineage

Murine AIDS (MAIDS) is caused by a defective retrovirus which encodes a gag fusion protein (Pr60gag). We previously reported that this virus induced an oligoclonal proliferation of infected cells and suggested that this cell expansion was an important event in the pathogenesis of MAIDS. To identify these target cells, we constructed novel defective viruses whose genomes could be detected with specific probes. Helper-free stocks of these viruses induced MAIDS. Using in situ hybridization and immunocytochemistry and Southern analysis, we found that most infected cells belong to the B-cell lineage. Transformation of these B cells appears to be the primary event responsible for the development of immunodeficiency. This animal model may be relevant to our understanding of AIDS, of the immunodeficiencies associated with B-cell lymphoproliferative disorders, and of the role of B-cell proliferation and transformation in the effects of superantigens, since Pr60gag appears to be a superantigen.

Bilateral ovarian involvement as the only manifestation of malignant lymphoma

A 16-year-old girl presented with a large pelvic mass. At laparotomy, bilateral ovarian tumors were disclosed and bilateral salpingo-oophorectomy was performed. No evidence of extra-ovarian disease was found. Histopathological examination and histochemical immunoperoxidase studies demonstrated the tumors to be malignant lymphoma of the lymphoblastic type. The patient had radiotherapy and systemic chemotherapy and more than 10 years later she is alive with no evidence of recurrent disease. The rarity of ovarian involvement as the initial manifestation of malignant lymphoma is discussed. The question of whether this patient represents a case of a primary ovarian malignant lymphoma or merely represents a case of ovarian initial manifestation of an occult generalized disease cannot be answered.

Pulmonary disease in the immunocompromised host. 1

With few exceptions, pulmonary complications in the immunocompromised host will proceed to death unless the clinician intercedes. The differential diagnosis of diffuse pulmonary disease in this setting includes (1) infection, most commonly from opportunistic organisms; (2) recurrence or extension of the basic underlying disease process to involve the lungs; (3) adverse pulmonary reaction to drugs; (4) a new, unrelated disease process such as cardiac pulmonary edema or pulmonary emboli; and (5) any combination of these categories. Up to a third of these patients have two or more complications, such as pneumonitis from two different opportunistic organisms or an opportunistic infection and a drug-induced pulmonary complication. An understanding of the host defense that is compromised enables the clinician to narrow the differential diagnosis. The most common types of impairment of defense mechanisms are reductions in the number of granulocytes, B-lymphocytes, or T-lymphocytes, and not uncommonly, two or all three of these types of cells are involved. Impairment of each of these cell types is associated with an increased frequency of infection by a particular group of organisms. Consequently, the clinician can be somewhat selective if empiric therapy is being considered. In the immunocompromised patient, most pulmonary complications, including drug-induced pulmonary disease and pulmonary emboli, are associated with fever that mimics an infection. Up to 25% of the pulmonary complications in these patients are noninfectious.

Histologic transformation in extranodal non-Hodgkin's lymphoma

Histologic transformation in the course of non-Hodgkin's lymphoma (NHL) has been reported to occur in 18 to 30% of the cases. Less favorable prognosis in cases with initial low grade malignancy followed by emergence of high grade malignancy has been previously described. In the previous literature, the histologic transformation has been examined mostly in nodal NHL. In the present study, histologic transformation in the course was investigated on 20 cases with early extranodal NHL. All these 20 cases were diffuse lymphomas, and were composed of 7 cases with low grade malignancy and 13 cases with high grade malignancy. Histologic transformation was not observed in any of these cases. These findings indicate that the frequency of histologic transformation is much lower in extranodal NHL than in nodal NHL. The prognostic significance of these findings is also discussed.

Monoclonal immunoglobulins with affinity for platelets and their relationship to malignant lymphoma

Monoclonal immunoglobulins with affinity for platelets were detected in the blood of seven patients. Two of these had thrombocytopenia and non-Hodgkin's lymphoma (NHL). One patient had thrombocytopenia and possibly incipient NHL. The other four patients had pseudothrombocytopenia at the time of diagnosis but one of them developed NHL six years later. It is suggested that these monoclonal immunoglobulins may in some cases be associated with malignant lymphoma and that subjects presenting with these immunoglobulins should have a long term follow-up in order to elucidate the question whether or not lymphoma will develop.

Effects of diphenylhydantoin on killer cell activity and other immunological functions. A sequential study including the interaction of Corynebacterium parvum in melanoma patients

The effects of a single Phenytoin dose, given to patients with malignant melanoma, upon peripheral blood counts, serum immunoglobulins, lymphocyte subpopulations and lymphocytotoxicity (using Chang target cells) were recorded. Sequential blood samples were taken before and 10, 14, 34, 38 and 58 h after the Phenytoin. Early reductions (P less than 0.05) in lymphocyte count, NK, K and PHA induced cytotoxicity, when compared with initial, pre-Phenytoin values were noted. Immunisation with i.v. C. parvum prevented the reductions occurring after a second dose of Phenytoin. Indeed, significant increases above the values of samples taken immediately before the second dose, were observed in T cells, PHA blastogenesis, NK and K cell Cytotoxicity. The second dose did however cause some immunosuppression; the increase in T cells, NK and PHA induced cytotoxicity above initial values expected from previous investigations were not observed. The immunosuppression, particularly of killer cell function, occurring after phenytoin could have implications for the pathogenesis of malignancy and transplacental carcinogenesis, reported as following Phenytoin exposure.

Complications from staging laparotomy for Hodgkin disease

Nonspecific complications from staging laparotomy are usually related to general anesthesia or abdominal exploration. Specific complications for the procedure do exist: intubation difficulties during administration of anesthesia to patients with untreated mediastinal disease, sepsis in up to 20% of patients, depending on stage of disease and intensity of postoperative chemotherapy and radiotherapy, arterial and possibly venous thromboemboli from extensive retroperitoneal node dissection, pancreatitis, small bowel obstruction from adhesions to node biopsy sites, operative mishaps, subphrenic abscesses, and bleeding from liver biopsies. Certain patient subpopulations are at especially high risk for some of these complications and their identification and possible measures to minimize such problems are proposed.

Malignant lymphomas as tumours of the immune system

Malignant lymphomas have traditionally been classified on solely morphological grounds. With new immunological and cytochemical techniques, it has been possible to characterize normal cells of the T-lymphocyte, B-lymphocyte, and monocyte-macrophage system. Application of these methodologies to malignant lymphomas has established their nature as neoplasms of the immune system. Within the B-lymphocyte system it is possible to identify subpopulations responsible for Burkitt's tumour, follicular (nodular) lymphomas, lymphocytic lymphomas of intermediate differentiation and well differentiated lymphocytic lymphomas. The T-lymphocyte system includes lymphoblastic lymphomas, mycosis fungoides, and Sezary's syndrome. Large-cell lymphomas are diverse, but the majority are tumours of transformed lymphocytes, usually of the B-lymphocyte system. The precise nature of the neoplastic cells of Hodgkin's disease (i.e., Reed-Sternberg cells and their mononuclear counterparts) has not yet been established. Despite previous suggestions of a B-lymphocyte or T-lymphocyte origin, recent studies with in vitro cultivation have strongly suggested derivation from the monocyte-macrophage system.

B and T lymphocytes in lymphoproliferative diseases of the skin. Effect of a thymic hormone on the immunocompetence of T lymphocytes

Cell-mediated immunity using the E-rosette technique, the graft-versus-host reaction and intradermal skin tests were investigated in two groups of patients, twenty-two with benign lymphoproliferative diseases of the skin (lymphocytic infiltration of the skin and lymphadenosis benigna cutis) and nine with malignant lymphoproliferative diseases (mycosis fungoides and lymphoma cutis). The effect of thymic hormone upon T lymphocytes which proved to have impaired functional capacity was investigated. Seventeen of the twenty-two patients with benign lymphoproliferative diseases were found to have intact cellular immunity whereas seven of the nine patients with malignant disease proved to be immunodeficient. The determination of immune competence may be of help in establishing the correct diagnosis in doubtful cases and might also be useful in the follow-up of these patients. The improvement in functional capacity of T lymphocytes resulting from their interaction with a thymic hormone indicates that it holds therapeutic promise.

Hodgkin's disease

During the past two decades, new approaches to the diagnosis and treatment of Hodgkin's disease have contributed to improved rates of survival and probable cure. Currently, patients with Hodgkin's disease are treated according to the stage and symptoms of their disease. The degree of certainty necessary for determining stage depends on the potential effectiveness of the therapeutic options available in a given case. Certain cases have been identified where treatment with a single modality has been disappointing, and the use of both radiotherapy and chemotherapy may be considered for these. Such decisions can be made only by evaluating the effectiveness of salvage after relapse following single-modality treatment and assessing the added hazards of initial treatment with both modalities.

The immunopathology of Hodgkin's disease

Answers are beginning to emerge to the questions posed in the introduction to the preceding section. In vitro techniques that allow characterization of malignant cells have particular relevance when, as in Hodgkin's disease, the precise identity of the cells remains in doubt. Monolayer tissue cultures derived from Hodgkin's disease tumours and maintained as established cell lines have proven amenable to a variety of cytogenetic, immunological, enzymatic, and ultrastructural studies. Tissue culture experiemnts, in conjunction with meticulous immunological studies of individual Reed-Sternberg cells from non-cultured tumours, suggest that neoplastic cells of Hodgkin's disease are related to, and possibly derived from, cells of the monocyte-macrophage system. The lymphocytes that comprise an integral part of the cellular proliferation and form the basis for histological subclassification of the tumour could be a manifestation of cell-mediated immunity against this non-lymphoid malignant cell. The immunodeficiency of patients with untreated Hodgkin's disease of limited anatomical extent is not the primary event of the disorder and probably not related to the site at which the aetiological agent acts. The deficit does not result solely from impaired T-cell function and appears to arise as a consequence of excessive suppressor cell activity. Inhibitory monocyte-lymphocyte interactions may be one of the causes of defective cell-mediated immunity in Hodgkin's disease. The possible significance of elevated levels of circulating immune complexes in the serum of patients with Hodgkin's disease is indicated by the finding that such complexes react with cells of long-term monolayer tissue cultures derived from the tumour. Circulating immune complexes may be one source for intracellular immunoglobulin in non-cultured Hodgkin's disease cells. The presence of polyclonal immunoglobulin G on the membrane and within the cytoplasm of Reed-Sternberg cells could be due to in vivo binding and ingestion of immune complexes by such cells. The specificity of the interaction between soluble complement-containing immune complexes and neoplastic cells of Hodgkin's disease depends on the nature of the complexed antigen. The complexes could non-specifically attach via an Fc receptor or, if the complexed antigen is identical to a tumour cell antigen, the binding could be specific. If the immune complexes are tumour specific they could provide a source for isolation and identification of tumour-associated antigens. However, the aetiological significance of antigens and putative oncogenic viruses thus far identified in association with Hodgkin's disease remains to be clarified.

CVP-remission-maintenance in stage I or II non-Hodgkin's lymphomas: preliminary results of a randomized study

The effect of adjuvant combination chemotherapy when given to non-laparotomized patients in remission after radiotherapy in stage I or II non-Hodgkin's lymphoma was studied in a prospective randomized multicenter study. Locally extended field radiotherapy was given to a target absorbed dose of 40 Gy in 20 fractions. Fifty-five patients who were in complete remission 6 weeks after conclusion of radiotherapy were randomized to either no further therapy or to 9 cycles of CVP (cyclophosphamide + vincristine + prednisolone). The relapse-free survival at 30 months was 41% for patients without and 86% for patients with adjuvant chemotherapy (p = 0.02). The survival was the same for both treatment arms, being 90% at 30 months. Fifteen patients have relapsed, 14 of them with extensions and 1 with a recurrence within the radiation target volume. Analysis of subgroups showed that adjuvant chemotherapy in the present series significantly prolonged the relapse-free survival in diffuse histiocytic lymphoma.

Acute myeloblastic leukemia two years after diagnosis of non-Hodgkin lymphoma

The 18-year-old white male developed acute myeloblastic leukemia (AML) 25 months after diagnosis of poorly differentiated lymphocytic lymphoma, diffuse pattern (PDLL-D), involving cervical, supraclavicular, and mediastinal lymph nodes as well as bone marrow. Treatment of the lymphoma consisted of 2,000 rads to the mantel area and 18 months of chemotherapy with intravenous (IV) methotrexate (400 mg/m2), vincristine, and prednisone, alternating every two weeks with IV cyclophosphamide (1,000 mg/m2), vincristine, and prednisone plus monthly intrathecal methotrexate. Thereafter, a complete remission was maintained without therapy until the onset of AML. Several pseudodiploid clones containing multiple structural rearrangements and a hypodiploid clone were identified in the circulating blood at the time of diagnosis of AML. Induction therapy consisting of cytosine arabinoside, 5-azacytidine, vincristine, and prednisone was unsuccessful, and the patient died of sepsis two months after diagnosis. This case calls attention to the increased risk for subsequent acute nonlymphocytic leukemia in patients previously treated for nonhodgkin lymphoma.

Lymphoma of the head and neck

The natural history of 88 cases of non-Hodgkin's lymphoma of the head and neck were reviewed. An analysis is presented of the histopathologic, clinical, and prognostic features of these patients which presented to the Washington University Affiliated Hospitals between 1955-1975. All biopsies were histologically classified according to the criteria of Rappaport and staged accordingly to the Ann Arbor Classification. There were 38 histiocytic lymphomas, 29 poorly differentiated lymphocytic lymphomas, 16 well differentiated lymphocytic lymphomas, and 5 mixed lymphomas. The lesions were equally divided between Waldeyer's ring and other head and neck sites. Most of the lymphomas were extranodal in presentation. Sixty-one percent of all cases presented with disease localized to the site of origin; 17% had extension to regional nodes and 21% had generalized disease (Stage III and IV). In terms of treatment, localized well differentiated lymphocytic lymphoma was treated with radiation therapy. Generalized well differentiated lymphocytic lymphomas were treated with radiation and chemotherapy. Most patients with histiocytic and poorly differentiated lymphocytic lymphoma limited to the site of origin were treated with radiation and all others with combined therapy. Over 90% of patients with Stage I disease were considered cured at the end of three years while the overall survival was 72%.

Malignant lymphoma of the faucial tonsil

Ten cases of malignant lymphoma of the faucial tonsil treated in the R.U.H., Bath, during 1965--1975 are reviewed. Dysphagia and irritation in the throat are predominant symptoms. Enlarged tonsil is the commonest feature. Radiotherapy is the treatment of choice and the prognosis has improved considerably with modern supervoltage radiotherapy.

[Electrophoretic mobility of lymphocytes in chronic lymphatic leukemia (author's transl)]

Lymphocytes and other blood cells can be separated by means of free flow cell electrophoresis. Immunofluorescence of the separated lymphocytes of four healthy volunteers with antiimmunoglobulins IgD and IgM produced different distribution profiles for each immunoglobulin class, the IgD positive cells migrating faster than the IgM positive ones. Amongst five patients with chronic lymphocytic leukemia four with IgD positive lymphocytes (greater than 80%) showed an identical electrophoretic distribution. The IgM positive lymphocytes (greater than 80%) of the fifth patient migrated much more slowly. The weighted mean of each distribution profile of either the IgD or IgM positive lymphocytes in CLL is similar to that of normal subjects.

Epidemiology of hodgkin's disease in the young

Many features of Hodgkin's disease (HD) among adolescents and young adults suggest that it has an infectious etiology. However, the proposal that HD is a contagious disease which can be transmitted by patients or their close contacts has not been substantiated. An alternative infectious disease model is suggested by analogy with paralytic poliomyelitis (PP). For both diseases, the peak age of incidence is delayed as living conditions improve. For both, increased risk is associated with higher social class and small family size. Like PP, HD may be a rare manifestation of a common infection with the probability of disease development increasing as age at infection is delayed. This analogy is supported by the report that the risk of HD is higher for persons who had a low frequency of childhood infectious diseases. If this model is valid, HD patients represent no hazard to their contacts. However, the incidence of HD among young adults may increase in the coming decade because of the current high standard of living and small family size.

Infections in patients with malignant lymphoma treated with combination chemotherapy

The records of 360 patients with malignant lymphoma treated with various forms of combination chemotherapy from 1966 to 1974 were reviewed. A total of 181 infections was found in 125 patients. The most frequent types of infection were pneumonia (31%), skin infections (17%), urinary tract infections (13%) and septicemia (11%). An etiologic organism was was identified in 133 infections (73%). The most common causative organisms were bacteria (77%), especially gram-negative bacilli. Viral infections accounted for 18% of the infections with 21 of the 24 being due to herpes zoster. These were more frequently found in patients with Hodgkin's disease (14/21) than in the other lymphomas. Among patients with Hodgkin's disease, 53% treated with COP developed infections compared to only 27% treated with MOPP (p = 0.039). Among patients with non-Hodgkin's lymphoma, infections were more frequent in patients treated with Adriamycin containing combinations than with COP. Neutropenia (i.e. less than 1,000 neutrophils/mm3) was associated with 35% of infections in this study and was seen more often in patients with non-Hodgkin's lymphoma (p = 0.048).

Basic concepts in Hodgkin disease

The following is an example of a typical case of Hodgkin's disease, which illustrates the use of clinical and pathologic staging procedures. A 40-year-old man had fever and swelling of the left side of the neck for two weeks. Physical examination showed enlargement of the left supraclavicular and left axillary lymph nodes but no hepatosplenomegaly. Biopsy of the affected lymph nodes showed Hodgkin's disease, mixed cellularity type. A chest roentgenogram, lymphangiogram. 67Ga scan, and results of bone marrow biopsy of the right iliac crest were normal. The clinical stage was classified as IIB2. (Subscript 2 indicates the number of regions of lymph node involvement. The patient subsequently underwent laparotomy. The spleen weighed 150 gm and contained microfoci of Hodgkin disease. Biopsy of an upper para-aortic lymph node at the L-1 showed involvement by Hodgkin disease, but specimens from either lobe of the liver, lower para-aortic and iliac lymph nodes, and left iliac crest did not. The pathologic stage was therefore classified as IIIN+H-S+M- Polychemotherapy was prescribed.

Histiocytic lymphoma (reticulum-cell sarcoma). Report of five cases

The subject of lymphomas is discussed and five cases seen in our Oral Surgery Department are Presented. Histiocytic lymphoma, especially of the oral regions, can present with a variety of clinical manifestations. The signs and symptoms, diagnostic modalities, and treatment are discussed and the most recent classification is included.

Fulminant sepsis after the successful treatment of Hodgkin's disease

Of 14 splenectomized patients with Hodgkin's disease who were treated with total nodal irradiation and combination chemotherapy (MOPP), fulminant sepsis developed in three (21.4 per cent) while they were in remission; two died within hours. Similar cases were not observed in a larger group of 146 patients with Hodgkin's disease (including 104 splenectomized patients who were treated less intensely). Our experience indicates the need for caution when asplenic persons are aggressively treated with both radiation and drugs.

Extensive primary lymphoma of the gastrointestinal tract

A case of extensive primary lymphocytic lymphoma (lymphosarcoma) of the gastrointestinal tract is reported. At the time of presentation the patient had diffuse involvement of the gastrointestinal tract from the stomach to the ano-rectal junction. Malabsorption was present. Pre-treatment immunologic studies showed elevated serum IgA and IgG, but impaired humoral and cellular immunity. Death occurred 13 months after diagnosis.

Morphological changes in the lymphoid organs induced by diphenylhydantoin sodium (DPH)

In rats injected with DPH the morphological changes induced in the thymus and lymph nodes were studied. In the thymus, features suggesting block of cellular differentiation were found, and in lymph nodes depletion of the paracortical zone and intense plasma cell hyperplasia could be observed. The correlation of these findings with the functional changes in the immunological response induced by the drug, and the possible implications of these changes in the induction of lymphoma are discussed.

Immunological characterization of lymphoproliferative disorders by membrane markers

The characterization of lymphocyte subpopulations by means of surface markers improved our understanding of the immunopathology of lymphoproliferative disorders. In chronic lymphocytic leukemia an accumulation of B-lymphocytes have been documented. The antibody deficiency syndrome in these patients might well reflect a maturation defect of the leukemic B-lymphocytes. In patients with Hodgkin's disease the relative number of B- and T-lymphocytes in the blood was not markedly altered in comparison to normal controls. An increased proliferation primarily of T-lymphocytes however, might suggest their accelerated turnover as an indication of the host response. In most patients with "Non-Hodgkin" lymphomas high numbers of B-lymphocytes were found in affected lymph nodes, and these appear occasionally in the peripheral blood. Differences in immunopathological manifestations of the various subgroups of the "Non-Hodgkin" lymphomas are emphasized and the rare occurrence of lymphomas of T-lymphocytes (mainly observed in lymphoblastic lymphomas and in Sézary syndrome) is discussed. Immunopathological alterations in immunocytomas and the myelomas are considered in respect to the involvement of B-lymphocytes at different stages of maturation.

Immune function of successfully treated lymphoma patients

Immunologic function was evaluated in 12 patients with Hodgkin's disease and 5 patients with lymphocytic lymphoma who had been successfully treated with either chemotherapy, radiation therapy, or both of these modalities 3-42 mo previously. Only two of the patients were found to have total anergy to a battery of six recall skin test antigens and all were responsive to skin testing with phytohemagglutinin. However, 10 of 16 patients were unable to develop delayed cutaneous hypersensitivity to either of the neoantigens dinitrochlorobenzene or keyhole limpet hemocyanin. Four other patients developed reactivity to only one of these neoantigens for a total of 14 of 16 (88%) of the patients demonstrating some impairment in neoantigen response. Total lymphocyte, T-lymphocyte, B-lymphocyte, and null cell numbers, as well as serum immunoglobulins were quantitatively normal. Monocyte numbers, chemotaxis, and Fc receptor activity were normal. Monocyte staphylocidal activity at 60 min was modestly depressed and candidacidal activity was depressed in those receiving both chemotherapy and radiation therapy. Spontaneous (unstimulated) lymphocyte [3H]thymidine incorporation was low in the patients as a group and lymphoblastic transformation to specific antigens was impaired in 11 of 17 patients who had positive skin test reactions to the same antigen. Highly significant suppression of lymphoblastic transformation was noted after stimulation by the mitogens phytohemagglutinin, pokeweed, and concanavalin-A. The greatest impairment of mitogen response was seen in those patients receiving both chemotherapy and radiation therapy. These data demonstrate specific impairments of neoantigen processing, lymphocyte function, and to a lesser extent monocyte function in successfully treated patients with lymphoma. These impairments may contribute to the increased incidence of infections and second primary malignancies in these patients.

Nonmalignant monoclonal immunoglobulinemia, pernicious anemia and gastric carcinoma. A model of immunologic dysfunction. Report of two cases and review of the literature

The association of an autoimmune disease with a monoclonal immunoglobulin is not exceptional and most probably results from a dysfunction of the immunologic apparatus. This study describes two patients with monoclonal immunoglobulin A (IgA) and M (IgM) gammopathy, respectively, in whom pernicious anemia and finally gastric carcinoma developed. One patient had autoantibodies to gastric parietal cell and to thyroid microsomal antigen which could not be identified with the M-component. This observation, together with the fact that pernicious anemia occurred in one case before and in the other case after the discovery of M-component, suggests that different clones of cells were responsible for both disorders. Sixteen cases in which the patients had the same association have been collected from the literature and the data are compared with ours.

Improved survival in hodgkin's disease

All patients below the age of 66 whose Hodgkin's disease was treated at the Massachusetts General Hospital between July 1, 1965 and June 30, 1973 were analyzed. The patients were divided into an early group seen before November 1, 1968 and a later group seen after that date. Survival and survival without recurrence were calculated by the actuarial method of Berkson and Gage, and compared with figures obtained from a historical series seen at this institution between 1948 and 1964. In the most recent period (1969-1973), 87% of patients with all stages of Hodgkin's disease were alive five years after diagnosis, a remarkable improvement over the 65% survival of the 1965-1968 group and the 34% survival of the historical series. The excellent survival of the recent group was a result of improved management of patients with advanced disease (Stages III and IV), most plausibly attributed to better appreciation of the extent of disease by surgical staging and to the shift from total nodal irradiation to combination chemotherapy for initial treatment of these patients. Recurrence after irradiation was extremely uncommon in patients in Stage IA and IIA (lymphangiogram-negative, asymptomatic) subjected to aging laparotomy, while similarly staged and irradiated patients in Stages IB and IIB (lymphangiogram-negative, symptomatic) did much less well. Except for the surgically staged patients in Stages IA and IIA, the continuing high relapse rate indicates that five-year survival, even when relapse-free, is not synonymous with cure, and emphasizes the need for caution in predicting the ultimate cure rate with current therapy.

T and B lymphocytes in non-Hodgkin's lymphoma: a comparison of tumor-derived cells and peripheral blood lymphocytes

T- and B-cell markers of lymphocytes in peripheral blood, involved node and spleen, PHA response of peripheral blood lymphocytes, serum immunoglobulin levels, and skin test reactivity to six common antigens were studied in 16 cases of untreated non-Hodgkin's lymphoma. Impaired response of peripheral lymphocytes to PHA was observed in 13 of 16 cases, regardless of the proportion of T lymphocytes. Of 12 cases in which skin tests were done, two were positive and had a normal PHA response, seven cases were positive in spite of low PHA response, and three were negative with low PHA response. In the lymph nodes from involved areas two cases showed monoclonal increase of B-cells, five showed "null" cell increase, and the remaining nine showed no increase or decrease of subpopulation of lymphocytes. No correlation with surface marker of lymphocytes to histologic classification was seen. From the above observations it was concluded: 1) a low PHA response in non-Hodgkin's lymphoma was not due to the decreased population of T-cells; 2) a low PHA response may not necessarily indicate impaired delayed hypersensitivity; and 3) non-Hodgkin's lymphoma can be classified in the following ways--B-cell proliferative type, "null" cell increase type, and normal T/B proportion type.

1,3-bis(2-chloroethyl)-1-nitrosourea(BCNU), cyclophosphamide, vincristine- and prednisone-(BCOP). A new therapeutic regimen for diffuse histiocytic lymphoma

Sixty-seven evaluable patients with mixed cellular and histiocytic lymphomas, both nodular and diffuse, were treated with a combined drug regimen of BCNU, cyclophosphamide, vincristine, and prednisone administered for six monthly courses. Of 28 previously untreated patients with diffuse histiocytic lymphoma, 14 (50%) achieved a complete remission, and an additional 7 (25%) had a good partial response for an overall remission rate of 75%. Complete remissions were also obtained among the small number of mixed and nodular histiocytic lymphomas which were treated. The median survival for previously untreated patients with diffuse histiocytic lymphoma who achieved a complete remission is nearly two years and 42% (8/19) of these patients remain in their initial unmaintained remission (range 2-119 weeks). Hematologic toxicity, although acceptable, was the limiting factor. Granulocytes were more often and more severely depressed than platelets.

Complications of abdominal exploration and splenectomy in staging children with Hodgkin's disease

Until alternate diagnostic methods are discovered, the staging procedure seems to be the most reliable method to establish the presence or absence of abdominal involvement in Hodgkin's disease. Our experience with staging laparotomy in 22 children raises serious questions as to both the risk of operation and the prognostic value of a negative abdominal exploration. Routine use of the staging laparotomy may not be justified in clinical Stage IA patients with lymphocyte-predominant cell type. Because of the hazards and limitations of the staging procedure, vigorous attempts would seem to be indicated to identify subcategories of patients in whom the likelihood of intraabdominal involvement is so small as to negate the value of surgical staging.

Advanced non-Hodgkins' lymphomas: response to treatment with combination chemotherapy and factors influencing prognosis

Response to combination chemotherapy with cyclophosphamide, vincristine and prednisone (COP) and specific factors influenceing prognosis were evaluated in 70 patients with stage III or IV non-Hodgkin's lymphomas. Complete remissions (CR) were observed in 40% of patients, with a total response rate of 88%. The median duration of CR was 8 months, but 50% of patients were in continuing CR. High rates of CR were associated with: (a) well-differentiated lymphocytic cytology, (b) tumour nodularity, (c) normal blood lymphocyte counts at diagnosis, and (d) disease stage IIIA. These same factors also showed a positive correlation with 5-year-survival rates from diagnosis. It is suggested that patients with advanced non-Hodgkin's lymphomas do not form a homogeneous treatment group, but warrant a differential therapeutic approach based on the prognostic determinants stated above. The study provides further support for the prognostic usefulness of Rappaport's classification of these tumours.

[Quantitative behavior of immunoglobulins in Hodgkin patients following splenectomy]

The values of immunoglobulins in 14 patients with malignant lymphoma were determined before and 1 to 44 weeks following splenectomy. The IgM-fraction showed a significant decrease in all cases, whereas the IgG- and IgA-fraction showed no change in its concentrations. The reason for the IgM-decrease is probably due to the absence of IgM-producing cells in the spleen.

The proliferative diseases of the lymphoreticular system. Classification and pathological features of malignant lymphomas

An histogenetic classification of lymphomas is discussed, and diagnostic criteria are proposed for these neoplasms, based primarily on their histological features and assessment of the predominant cell population in the individual lymphomas. Limitations of space ane experience have precluded more comprehensive discussions on the morphology of malignant lymphomas in relation to their immunological, functional and clinical features, prognosis and response to therapeutic agents. Since we are aware that the proposed classification and histological criteria are incomplete and imperfect if the malifnant lymphomas are considered as static entities, we wish to conclude our paper by quoting a statement made by Rappaport23: '...the clinical usefulness of any classification of reticular neoplasms is limited by their often unpredictable behaviour'.