Intestinal lymphoma and sprue: a systematic approach

Latent Epstein-Barr virus infection is an unlikely event in the pathogenesis of immunoproliferative small intestinal disease

BACKGROUND

The observed seasonal and geographic variations in the incidence of immunoproliferative small intestinal disease (IPSID) suggest that environmental factors contribute to its pathogenesis. One such environmental factor, the Epstein-Barr virus (EBV), has been associated with other B-cell lymphoproliferative disorders.

METHODS

IPSID tissues obtained at the time of initial diagnosis were retrieved from the American University of Beirut pathology archives (1972-1983) and examined for EBV genetic information by colorimetric in situ hybridization (ISH) and polymerase chain reaction (PCR). Eight patients were identified, four of whom also had serologic and immunohistochemical evidence of alpha-heavy chain disease. Thirteen tissue samples from these eight patients were available for study: eight were intestinal and five were nodal. Non-Hodgkin's B-cell lymphoma cases (nine) were randomly selected from the same archive to serve as a control for EBV in that geographic location. The ISH method used a probe to the "W" repetitive region of EBV, with the human placental DNA probe as a control for sample preparation. The PCR method amplified a 110 base pair region in the long internal direct repeat with amplification of beta-actin as control for DNA preservation. Both assays used formalin fixed paraffin embedded Raji cells as a positive control.

RESULTS

Neither ISH nor PCR demonstrated EBV in any of the eight patients with IPSID: The results for one of seven control blocks with adequate DNA preservation were positive when PCR was used but were negative when ISH was used.

CONCLUSIONS

These findings do not support a role for EBV in the induction of B-cell proliferation in IPSID:

Malignant lymphoma in coeliac disease: various manifestations with distinct symptomatology and prognosis?

OBJECTIVES

To study the different forms of malignant lymphoma complicating coeliac disease in a low-prevalence area, according to extranodal-nodal and extraintestinal-intestinal manifestations.

SUBJECTS AND SETTING

Patients recruited from two University Hospitals (Amsterdam, Leiden) and from PALGA (National Dutch data-bank) over a 16-year period.

DESIGN

Review of hospital charts with respect to clinical presentation and treatment of both coeliac disease and malignant lymphoma. Re-evaluation of morphology and staging by immunoperoxidase, enzyme- and immunohistochemical stainings on unstained and frozen materials.

MAIN OUTCOME MEASURES

Clinical behaviour and T- or B-cell morphology of extranodal intestinal, extranodal extraintestinal and nodal intestinal disease.

RESULTS

Fourteen cases of enteropathy-associated lymphoma could be traced, 10 with a history of coeliac disease, four primarily presenting with malignant lymphoma. The usual extranodal intestinal lymphoma (eight cases) presented with abdominal pain, weight loss, and malabsorption. Six had atypical disease: four presented with extranodal extraintestinal disease, located in the skin or the respiratory tract; two patients had intractable malabsorption and oedema caused by a nodal intestinal lymphoma. Re-evaluation with additional immunohistochemical stainings in 11 patients showed a pleomorphic malignant infiltrate of histiocyte-like cells of T-cell origin, with a pattern of CD3+; CD4-; CD5 +/-; CD7+ and CD8-. It also established a more appropriate diagnosis in four, an 0.6-year earlier diagnosis in six, and an upgraded stage of disease in two patients. A more extensive spread and poorer outcome appeared to become more probable in the ranking order of extranodal intestinal, extranodal extraintestinal and nodal intestinal lymphoma.

CONCLUSIONS

A proper and timely diagnosis of enteropathy-associated lymphoma requires clinical vigilance and unrelentless perseverance to obtain adequate fresh and frozen tissue for histochemical staining. Further research in a larger number of patients is warranted to investigate the relation between the primary site of the lymphoma, i.e. extranodal intestinal, extranodal extraintestinal, or nodal intestinal, and (its impact on) clinical presentation and prognosis.

A case of primary T-cell lymphoma of the duodenum

Primary malignant lymphoma located in the duodenum is a rarity. A case of primary lymphoma of the duodenum in a 27-year-old man, in which the 2 discrete masses of duodenal bulb and the second portion with pancreatic head invasion was found, is reported here. Immunohistochemical evaluation of the present case showed that lymphoma cells expressed the T-cell markers MT1 and UCHL1. Treatment consisted of pancreaticoduodenectomy followed by antineoplastic chemotherapy.

Combination chemotherapy for primary small intestinal lymphoma in the Middle East

Twelve patients with primary small intestinal lymphoma were followed prospectively for 3 years. Endoscopic abnormalities were diagnostic of lymphoma in all cases where the duodenum was involved (83%). In three cases (25%) the disease extended to the stomach. One patient (8%) had diffuse small cell cleaved and 11 (92%) diffuse large cell lymphoma stages I (8%), II (25%), III (58%) and IV (8%). Nine of them were unresectable and primarily treated with combination chemotherapy; 67% achieved complete remission, 22% partial response and 11% no response. Only one patient relapsed and achieved a second remission. All complete remission patients are currently alive and free of disease at a median follow-up of 36 months. Overall survival for all patients is 58%, and disease-free survival is 50%. No instance of chemotherapy-related bleeding or perforation was seen. Tetracycline was necessary for the treatment of IPSID-associated diarrhea and malabsorption in spite of cytotoxic chemotherapy.

Immunoproliferative small intestinal disease and primary small intestinal lymphoma. Relation to alpha chain protein

Forty-three patients with immunoproliferative small intestinal disease and primary small intestinal lymphoma were studied prospectively. Eighteen patients in whom alpha-chain protein was detected in the serum had significantly more features of malabsorption, and disease was localized more commonly in the jejunum. In all of these patients, a diffuse lymphoplasmacytic infiltrate was found in the intestine; in three patients lymphoma was found only in mesenteric lymph nodes. Twenty-five patients with lymphoma in whom alpha-chain protein failed to be detected had significantly more features of intestinal obstruction, and disease was found more commonly in the ileum. Five of these patients had lymphoma associated with a diffuse mucosal infiltrate that was indistinguishable from the first group. In patients available for follow-up, no difference was found in cumulative survival over 30 months in the two groups, with approximately 40% mortality at 6 months.

Primary gastrointestinal non-Hodgkin's lymphomas. A retrospective clinicopathologic study of 150 cases

The records of 150 primary gastrointestinal (GI) lymphomas in adults collected from 1974 to 1982 at the Department of Pathology, University of Vienna, were reviewed. One hundred thirty-three cases of malignant lymphomas (ML) were analyzed with respect to histologic type, presenting tumor stage, and clinical course, as well as for factors influencing prognosis. The histologic type of ML as assessed by the Working Formulation and the Kiel, the Lukes and Collins, and the Rappaport classifications showed only a minor influence on prognosis. MLs of follicular center cell origin prevailed in the stomach and large cell, immunoblastic MLs prevailed in the bowel. Immunoperoxidase studies indicated a B-cell nature of GI MLs and demonstrated intracytoplasmic IgM kappa or lambda in most of the MLs of the small lymphocytic, plasmacytoid, and immunoblastic type, respectively. The 105 cases of gastric MLs represented 3.6% of all malignancies of the stomach collected during the study period. Clinical symptoms preceded the diagnosis by 4.4 months on average, and endoscopic biopsy specimens indicated malignancy in 78%. Presenting tumor stages of gastric MLs according to the Ann Arbor staging system were Stage I in 20%, Stage II in 76.2%, and Stage IV in 3.8%. The 28 cases of intestinal ML localized in the small and large bowel without any site prevalence presented with Stage I in 14%, Stage II in 82%, and Stage III in 4%. Tumor resection was performed in 90% of all cases and was followed by multiagent therapy in 53%. Radical tumor resection was obtained in 58% of the gastric MLs and only 28.6% of the intestinal MLs and was closely related to tumor stage. Statistical analysis demonstrated a significant influence of the presenting tumor stage on prognosis as expressed by the overall 2-year survival rate of 70% for Stage I versus 39% for Stage II ML. In addition, Stage II1 according to Musshoff et al. run a better course than II2 as shown by the disease-free 2-year survival rate of 49% versus 15%, respectively. Radical tumor resection was a major determinant of survival and cure of disease as exhibited by the disease-free 2-year survival rate of 57% after radical resection versus 8% after nonradical resection of ML. Finally, diffuse tumor growth and tumor penetration of the gastric wall beyond serosa decreased the survival rates.

Primary non-Hodgkin's lymphoma of the duodenum. Case report and literature review

A case of primary non-Hodgkin's lymphoma of the duodenum is presented. A review of the English literature documented 95 cases, and the presenting signs, symptoms, and radiographic findings have been abstracted. Attention is also drawn to the treatment of 27 cases, 11 of which (41%) survived for 2 or more years. Ten of the 11 long-term survivors were treated with radiotherapy with or without resection, whereas only one long-term survivor was treated by surgery alone.

Evidence of acquired immune deficiencies in Mediterranean lymphoma. A possible aetiological link

Patients with Mediterranean lymphoma (M.L.) had a significant reduction in humoral immunity (IgG and IgM) as well as impaired cellular immunity (50% were anergic to three antigens--P.P.D., mumps, and dinitrochlorobenzene). Any hypothesis for the pathogenesis of M.L. has to account for the peculiar geographic distribution of the disease, the age and sex incidence, the plasma-cell nature of the tumours, the associated heavy plasmacytic proliferation with relatively intact intestinal mucosa, involvement of the proximal small intestine, and alpha-chain production in a large proportion of patients. All areas in which M.L. is common are currently involved in the seventh cholera pandemic. Vibrio cholerae toxin inhibits both immediate and delayed immune reaction in vitro through its effect on cyclic adenosine monophosphate. V. cholerae antigens stimulate the proliferation of IgA-producing immunocytes in the mucosa without deeply penetrating the mucosa. The proximal small bowel is usually affected by the disease but there is little epithelial damage. The population in endemic areas is continuously exposed to V. cholerae antigens and toxins. It is suggested that such exposure, under certain genetic or other circumstances, may produce a state of immunosuppression in the gut thus accelerating, predisposing to, or producing lymphoplasmacytic neoplasia.

Premorbid psychological factors as related to cancer incidence

In planning for studies relating psychological factors and/or stress (PF&/oS) to cancer, one should be aware of epidemiological findings that might contribute to or even account wholly for any found relationships. Most studies have not examined the known biological causes of cancer, nor have they described a rationale for relationships sought. The two broad mechanisms leading to cancer, carcinogens and lowered resistance to it, include physical and chemical causes, viruses and chronic infection, medication, genetic predisposition, hormonal stimuli, and aging. Interfering variables may bias or dilute a real relationship. Validity and reliability of instruments measuring PF&/oS are so variable as to warrant considerable care in their use. The latent periods of different cancers are measured in years, not months, with consequent potent impact on possible inferences drawn from prebiopsy and short prospective studies. In these and in retrospective studies, cancer can have strong and biasing effects on apparently straightforward PF&/oS measurements, as can iatrogenic effects. Some theoretical issues are discussed. The known prospective studies are discussed and reasons are given for the view that they are less convincing then many seem to think. A sketch of a model relating PF&/oS to cancer appearance is outlined, with some theoretical implications, and issues in research design are addressed.

Alpha-chain disease and its association with intestinal lymphoma

Twenty-seven intestinal lymphoma patients were studied. Abnormal alpha-chain immunoglobulin was detected in the sera of seven of these patients. The alpha-chain disease patients were from the rural areas of Southern Iran. They were of low socio-economic status and their age ranged from 15-44 years. Predominant clinical features were malabsorption, diarrhoea , abdominal pain, vomiting, and weight loss. Infiltration of mucosa of the small intestine with plasma cells and also distortion and flattening of the villi were common histopathologic characteristics of these patients. Involvement of mesenteric lymph nodes with infiltration of tumour cells was observed in a number of cases. Protein studies revealed no significant differences between the serum immunoglobulin levels of these patients and normal values. Immunoelectrophoresis using monospecific antiserum against H-chain of human IgA demonstrated the abnormal precipitin band of alpha-chain disease protein.

Persistent cell mediated immune-deficiency following infantile stress during the first 6 months of life

The cell mediated immunity as expressed by 2,4 DNCB skin sensitivity was measured in 50 healthy Iranian orphans of the age from 15 years. Complete records of the development of these children from birth were available. Children with severe gastroenteritis leading to marasmus and temporary thymic atrophy during the first 6 months of life showed a persistent atopy 1-5 years later. Less severe disease during this time lead to hyporesponsiveness. Similar stress after the 6th month of life did not lead to persistent changes in their cell mediated immunity. The implications of this for the epidemiology of neoplasia and infectious disease are discussed.

Primary upper small-intestinal lymphomal A report of 40 cases fron Iran

Primary upper small-intestinal lymphoma (PUSIL) has now been recognized as a distinct clinical entity with a distinct geographic distribution. Herewith are presented 40 cases of PUSIL seen at Pahlavi University Hospitals in Southern Iran. The investigation reveals the lymphoma to be predominantly a disease of those under 30 and males; the major complaints and physical findings point to an intraabdominal disease. An exception has been clubbing and osteoarthropathy. Special features of PUSIL include: (1) protein loss into the gastrointestinal tract leading to hypoalbuminemia and edema; (2) an antibiotic-responsive diarrhea and steatorrhea; and (3) an associated abnormal heavy-chain protein. The study further stresses the importance of peroral small-intestinal biopsy and the pathologic features of this condition.

Immune modulation and disease patterns in population groups

A hypothesis which explains disease prevalence among different socio-economic groups following early infantile modulation of cell-mediated immunity by infection and nutrition related stress is presented. Wealthy populations living under highly hygienic circumstances can develop their cell-mediated immunity to genetic expectation while their humoral systems remains unstimulated. Primitive populations protect the infant's immune development by breast feeding and suffer from temporary cell-mediated immune deficiencies due to intercurrent infectious disease and famine later on. Intermediary populations harbour a small percentage of people, whose cell-mediated immune system has been permanently damaged by infection in early childhood, leading to a high incidence of diseases linked to cell-mediated immune deficiency. The possible cocarcinogenesis of the cell-mediated immune deficiency following repeated gastroenteritis and persistent stimulation of B cells, leading to alpha heavy chain disease and primary intestinal lymphoma, or due to falciparum malaria in newborns and its impact on the EB virus genome in development of Burkitt's lymphoma, are discussed.

Primary intestinal lymphoma and its relation to alpha heavy chain disease

Primary intestinal lymphoma in young adults is a disease that occurs mainly in underprivileged populations. There is evidence that in some cases this disease evolves from a benign lymphoplasmocytic infiltration of the gut with alpha heavy chain. More studies are needed on the effect of environmental and genetic factors on the evolution of this disease. The role of oncogenic viruses in the development of intestinal lymphoma with malabsorption is an open question. Regional studies on the entity of intestinal lymphoma with malabsorption and its relationship to childhood lymphoma in the same populations are warranted.

Sprue in the Middle East: five case reports

Tropical sprue is a well documented condition with a special geographical distribution. This paper describes five patients with unexplained malabsorption whose symptoms began during a period of residence in the Middle East or Mediterranean areas.