B-prolymphocytic leukaemia--a mantle zone lymphoma?

The clinical and diagnostic relevance of CD23 expression in the chronic lymphoproliferative disease

BACKGROUND

CD23 antigen is a cell surface protein considered important in the differentiation of chronic lymphocytic leukemia (CLL) from other lymphoid leukemias.

METHODS

To better clarify CD23 role as a diagnostic tool, the authors retrospectively evaluated clinical and laboratory features of 372 patients who were referred to M.D. Anderson Cancer Center with a diagnosis of CLL or B-cell chronic lymphoproliferative disease.

RESULTS

Most of the patients (91%) were CD19+/CD5+. Only 6% of these CD19+/CD5+ patients were CD23-. Overall, CD23- patients had the worse prognostic features compared with CD23+ cases, including anemia (P = 0.03), massive splenomegaly (P = 0.000), high lactate dehydrogenase (P = 0.007), high beta2-microglobulin (P = 0.006), older age (P = 0.001), and male gender (P = 0.02). Surface immunoglobulin expression was moderate/strong in 19 (82%) patients, and FMC-7 was positive in 22 (96%) patients. None of the 13 patients tested for CD10 expressed the antigen. Based on morphology, of the CD23, 16 (70%) were diagnosed with mantle cell leukemia (MCL) was diagnosed in 16 (70%) CD23- patients, 3 (13%) with splenic marginal-zone leukemia, 3 (13%) with prolymphocytic leukemia (PLL) or PLL/CLL, and 1 (4%) with CLL. No cyclin D1 protein expression was noted by Western blot analysis in the one case that showed typical CLL morphology, and this patient did not require therapy. On the whole, the survival rate of CD23- patients was significantly worse than that of patients with CD23+. In contrast, 15 of 32 (49%) CD19+/CD5- patients were CD23-. CD23 negativity in this group was not associated with distinct clinical features or outcome. Eleven (73%) of these patients were classified as having splenic marginal-zone lymphoma and 4 as having follicular lymphoma.

CONCLUSIONS

These data indicate that CD23 negativity is rare in typical B-cell CLL, and CD23 negativity in patients with CD19+/CD5+ is suggestive of mantle cell leukemia a more aggressive disease with poor response to conventional therapy in which newer chemotherapy regimens such as hyper-CVAD may be more effective.

Overexpression of the PRAD1 oncogene in a patient with prolymphocytic leukemia with t(11;14)(q13;q32)

Prolymphocytic leukemia (PLL) was diagnosed by morphologic and immunophenotypical studies in a 72-year-old Japanese man. Massive splenomegaly was present but lymphadenopathy was minimal in this case. Chromosomal analysis of peripheral mononuclear cells showed t(11;14)(q13;q32) in all metaphases examined, except for one normal karyotype. Northern blot analysis of RNA prepared from leukemic cells obtained from the patient revealed overexpression of the PRAD1/cyclin D1 proto-oncogene, which has not been described previously in patients with PLL.

Atypical chronic lymphocytic leukaemia with t(11;14)(q13;q32): karyotype evolution and prolymphocytic transformation

In order to define better the cytological and clinical features of atypical B-cell chronic lymphocytic leukaemia (B-CLL) with t(11:14)(q13;q32), sequential morphologic immunological and cytogenetic studies were performed in seven patients belonging to a series of 72 consecutive cases presenting with a diagnosis of CLL or atypical CLL according to the FAB criteria. Cytologic diagnosis in these seven patients with t(11;14) was typical CLL in two cases presenting with < 10% large lymphocytes (LL) and prolymphocytes (PL) and atypical CLL in five cases in which LL and PL comprised between 10% and 55%. The diagnosis was supported by histologic findings on bone marrow biopsy (five cases) or splenectomy specimens (two cases). A progressive increase of peripheral LL and PL was observed, resulting in a switch of FAB diagnosis over a 6-60-month period from typical CLL into atypical CLL in two cases and from atypical CLL into prolymphocytic leukaemia in five cases. Immunophenotyping showed a mature B-cell phenotype with CD19, CD22, CD24 positivity and CD10 negativity in all patients. A bright-staining pattern for surface immunoglobulins (SIg) was detected in 6/7 cases, CD5 positivity in 6/7 cases, and CD23 positivity in 1/7 cases. The FMC-7 monoclonal antibody was positive in > 40% cells in 5/6 cases. Chromosome changes in addition to t(11;14) were seen in five cases; in two cases unbalanced translocations involving the 3q21 chromosome region, resulting in partial trisomy for the long arm of chromosome 3, were detected early in the course of the disease. Karyotype evolution that was associated with disease progression occurred in 3/6 assessable patients. Comparison of these findings with similar data from 65 B-CLL patients without t(11:14) showed that atypical morphology, switch of FAB diagnosis during the course of the disease, and karyotype evolution were more frequently seen in cases with t(11;14) (5/7 v 15/65 cases, P = 0.015, 7/7 v 7/65 cases, P < 0.0001, and 3/6 v 5/45 assessable cases, P = 0.04, respectively). The frequency of positivity for CD23 and bright SIg staining differed significantly in the two groups. It is concluded that t(11;14) identifies a cytologically atypical subset of B-CLL, characterized by frequent cytologic and cytogenetic evolution and by a distinct immunological profile, sharing some biological features with mantle cell lymphoma.

Immune marker expression in 53 lymphomas of high-grade malignancy

Tissue from 53 non-Hodgkin's lymphomas of high-grade malignancy according to the Kiel classification were analysed for cellular immunological markers. In most cases studies were performed in parallel on cell suspensions and cryostat sections. Histologically, the lymphomas were classified as anaplastic centrocytic (four), centroblastic (seven), Burkitt type (three), convoluted-cell type (five) lymphoblastic-unclassified (10), immunoblastic (IBL) (19) and pleomorphic T-cell type (five). Immunological phenotyping resulted in 60% B lymphomas characterized by monotypic surface membrane Ig (SmIg) and/or cytoplasmic Ig (CIg), and 23% T lymphomas with detectable E receptors; 17% of cases were non-expressive (O-type). Unusual SmIg-types were noticed in some monoclonal proliferations. Gamma (gamma) and mu chains occurred simultaneously in four cases; delta chain was the only heavy-chain in one case and a heavy-chain was absent in one case. Cases of IBL were of T-cell type in two cases, and two other cases were non-expressive. The cases of B-IBL expressed CIg in 93%, but the B lymphomas other than B-IBL only in 38%. Receptors for Fc-IgG and C3 were expressed by all major immune phenotypes (B, T, O), but were infrequent in lymphoblastic lymphoma unclassified (O-type). Adoption of immunological techniques to include frozen tissue studies was necessary in order to reach a conclusion regarding the immune phenotype in several cases.

A clinicopathological study of 13 Danish Cases of Burkitt's lymphoma

During a 4-year period 24 cases of malignant non-Hodgkin's lymphomas were proposed to be of the Burkitt-type (BL) by at least 1 of 5 pathologists of the lymphoma Registry in Jutland, Denmark. When the histological material was critically reviewed the diagnosis could be maintained in only 13 cases. 9 of the remaining 11 cases were immunoblastic lymphomas (IBL). Immunohistochemical stainings for cytoplasmic Ig-chains revealed generally weak reactions in the cases of BL. A distinct B-zone homing phenomenon first appearing in the lymphocytic mantle zone was observed in several lymph nodes from 2 patients with BL. In the BL-group the correlation between initial clinical stage and survival was satisfactory, the 2-year survival rate being 38% in the total BL-group. The incidence of BL was 2.1% of the malignant non-Hodgkin's lymphomas in the registry.

Surface IgM kappa of prolymphocytic leukaemia cells with antibody activity to surface antigens of sheep and guinea-pig red blood cells

The immunological findings of a B-cell prolymphocytic leukaemia forming spontaneous rosettes with sheep (SRBC) and guinea-pig red blood cells (GPRBC) are reported. The B-cell lineage was revealed by Ia-like antigen, surface IgM kappa and lack of cytotoxicity of anti-human T-cell serum. Despite B-cell characteristics, prolymphocytes formed spontaneous rosettes with SRBC. Inhibition procedures demonstrated rosette formation to be the result of antibody activity of surface IGM to SRBC and GPRBC. Pretreatment of prolymphocytes with pronase or antibodies to mu or kappa-chains inhibited rosette formation. Furthermore, pre-treatment of SRBC with the patient's serum or IgM decreased rosette formation demonstrating circulating antibodies to antigen(s) of SRBC. Antigen(s) on SRBC and GPRBC are not related to Forssman or Paul Bunnel antigen.

Large-cell T-lymphoma with hypersegmented nuclei

Clinical, morphological, cytochemical and immunological features in a case of T-lymphoma in a 67-year-old man are presented. Clinically, a predilection for lymph nodes was observed with a subsequent tumour-like spread to the liver, lungs and, to a minor extent, to the bone marrow. The skin, the spleen and the thymus were spared. Morphologically, the neoplastic lymphoid cells were characterized by their large size and particularly by their hypersegmented nuclei with a relatively coarse chromatin and large nucleoli. Cytochemically, a T-cell-like staining pattern in the acid phosphatase and in the acid alpha-naphthyl acetate esterase stains was absent. The neoplastic lymphocytes demonstrated a strong binding with sheep erythrocytes in suspension and in cryostat tissue sections. The morphological features of this lymphoma appear distinct from other non-Hodgkin's lymphomas. The similarities and the differences of our case in relation to some recently described cases of peripheral T-lymphomas comprising large cells with hyperlobated nuclei, are discussed.

Histological and immunopathological studies in a case of chronic Epstein-Barr virus infection terminating in a Burkitt-like lymphoma

A 6-year-old boy suffered from a severe lymphadenopathy, characterized histologically by a fulminant polyclonal immunoblast proliferation simulating malignant lymphoma with many immunoblasts resembling Reed-Sternberg cells. He had no history of infectious mononucleosis but Epstein-Barr virus (EBV) infection was evident from serological findings, and EBV-associated nuclear antigen (EBNA) was demonstrated in a high percentage of lymphocytes of blood and lymph nodes. An adequate humoral response to EBV ruled out the possibility of an X-linked recessive lymphoproliferative syndrome as the underlying cause of chronic EBV infection. A chromosomal defect in a subpopulation of lymphocytes was induced by interferon and might somehow be associated with a subtle immunodeficiency of our patient. After exacerbation of the disease chemotherapy was included in the treatment but the patient died 9 months after the onset of the disease. At autopsy the lymphoblastic cell proliferation had changed from that of immunoblasts to cells resembling the Burkitt's lymphoma cells. A change of the proliferating cell type was supported by means of cytochemical and immunological cell markers. The presence of EBV in these cells was demonstrated with the EBNA technique. It is concluded that our case may well support the hypothesis, that EBV may induce lymphoma-like polyclonal immunoblast proliferation in immunodeficient individuals, and that occasionally a monoclonal proliferation of the Burkitt's lymphoma type may supervene.