Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 13-1980

Urinary monoclonal free light chains in primary Sjögren's syndrome: an aid to the diagnosis of malignant lymphoma

Three patients, two with typical primary Sjögren's syndrome (SS) and the third with several features of SS, including abnormal sialography and reduced tear secretion, developed B cell non-Hodgkin's lymphoma (NHL) of parotid or lung, or both. Isoelectric focusing of concentrated urine specimens in agarose, followed by immunofixation, demonstrated the presence in each patient's urine of monoclonal free light chains of the same class as that shown on the tumour cells. In one patient the level of urinary free light chains was monitored and found to correlate with disease activity. Similar techniques showed no monoclonal light chains in the urine from a further 26 cases of SS with no clinical evidence of lymphoma. The detection of monoclonal urinary free light chains may provide an early diagnostic clue to the development of lymphoma in patients with SS and be a means of tumour monitoring.

Well-differentiated lymphocytic lymphoma. A study of 47 patients with primary manifestation in the lung

Forty-seven cases of primary well-differentiated lymphocytic lymphoma (WDL) of the lung were studied. Diagnosis was based on histologic identification of a lymphangitic pattern of infiltration and monomorphous (homogenous) cytologic composition. Nineteen cases (40%) had ancillary evidence supportive of a diagnosis of lymphoma including simultaneous or subsequent involvement of other organs, monoclonal immunologic markers, or a monoclonal serum gammopathy. The prognosis for the group as a whole was excellent; follow-up (median, 4 years) was available for 33 cases. Only one patient has died of lymphoma. The authors discuss the histologic differential diagnosis of lymphocytic infiltrates in the lung, propose criteria to distinguish reactive from neoplastic lymphocytic lesions, and discuss the significance of monoclonality in the management of these patients.

Computed tomography in acute disseminated encephalomyelitis

Computed tomographic (CT) scans were obtained for eleven patients with acute disseminated encephalomyelitis (ADE). Four patients had normal CT scans despite repeated examination. Abnormalities were found in seven patients and included cortical-enhancing lesions, low-density lesions in the deep white matter and basal ganglia, and edema of the brainstem. These findings support the hypothesis that both vascular injury and demyelination are involved in the pathogenesis of ADE. A delay between the onset of clinical signs and the appearance of lesions on CT scan was common. Clinical improvement was accompanied by improvement in CT abnormalities. There was a limited correlation between the clinical course and the anatomical distribution and type of abnormality seen on CT scan.

Primary gastric lymphomas. A clinicopathologic study of 58 cases with long-term follow-up and literature review

A large series of primary gastric lymphomas with long-term follow-up (average, 12.8 years) is reported. A number of factors known to affect nodal lymphoma were examined. Five- and ten-year survival rates were 57 and 46%, respectively. Statistically significant favorable prognostic variables were smaller tumor size (less than or equal to 7 cm), superficial mural invasion (submucosal only), and pathologic Stage I disease; these variables were intimately interrelated. A favorable influence on survival was discerned concerning histologic type and nodular histology, although still below statistical significance. No significant relation to survival was observed concerning clinical weight loss or palpable mass, vascular invasion, mode of therapy, or histologic subtypes of "histocytic" lymphoma. Of patients who succumbed to disease, 75% did so within two years (average, 1.8 years); however, later recurrence and death may occur. An argument for resection of localized disease is presented. Mitotic index and nuclear diameter were of diagnostic importance, and associated lesions such as pseudolymphomas are discussed in relation to pathogenesis. Histologic variation within tumors suggested visualization of clonal development in non-Hodgkin's lymphomas.

Immunoblastic lymphoma arising in chronic lymphoid hyperplasia of the pulmonary interstitium

Chronic pulmonary lymphoid hyperplasia occurs alone or is associated with a variety of disorders of the immune system. It may be a diffuse or localized process and has been referred to as lymphoid interstitial pneumonitis or pseudolymphoma, respectively. Chronic lymphoid hyperplasia in other organs has been followed by the development of malignant lymphoma, particularly when associated with disorders of the immune system. This report describes two patients with chronic hyperplasia of the pulmonary interstitial lymphoid tissue who had malignant lymphoma, immunoblastic type found at autopsy. Long-term steroid usage in one patient suggests the possibility that immunosuppressive therapy may increase the risk of developing malignant lymphoma in patients with chronic pulmonary lymphoid hyperplasia.