Splenic Lymphoma with Villous Lymphocytes

Hyperreactive malarial splenomegaly in expatriates

Hyperreactive malarial splenomegaly, one of the major causes of splenomegaly in tropics, has been often reported in expatriates of non-tropical settings. Essential features are recurrent malarial infection, overproduction of IgM and hyperplasia of lymphoreticular system. The practice of diagnosing the condition by exclusion of obvious causes of splenomegaly in the tropics has been abandoned. There are specific criteria for the diagnosis. Huge splenomegaly >10 cm below costal margin, serum IgM more than 2 x standard deviation (2SD) above the local mean, high titre of malarial antibodies and response to antimalarial drugs are the cornerstones of the diagnosis. Splenic lymphoma with villous lymphocytes coexists with this condition and it should always be considered in the differential diagnosis of unresponsive or poorly responsive cases of hyperreactive malarial splenomegaly. Condition with fever and acute haemolysis in HMS has been termed as Fulminant tropical splenomegaly syndrome. Treatment of the condition depends on antimalarial (chloroquine/ proguanil/ pyrimethamine) chemoprophylaxis for 1 year or more.

Patterns of bone marrow involvement in 58 patients presenting primary splenic marginal zone lymphoma with or without circulating villous lymphocytes

We studied 86 bone marrow biopsies (BMB) from 58 patients presenting with primary splenic marginal zone lymphoma (PSMZL). In 42 patients, a splenectomy was performed which enabled a histopathological diagnosis. In these patients, 44 biopsies were carried out before, and 25 after, splenectomy. In 16 recently observed patients, 17 BMB led to PSMZL diagnosis, and these patients were treated without splenectomy. Seven different patterns of infiltrates were recognized: intravascular, interstitial, nodular, massive, plasmacytic mimicking myeloma and transformation into large B-cell lymphoma (DLBCL). The association of an intravascular infiltrate and nodules with a germinal centre and/or a marginal zone favoured a diagnosis of MZL. Immunohistochemistry demonstrated the expression of B cell-associated antigens and, in 40% of the patients, a monotypic lymphoplasmacytic cell component. These patients often presented a serum M component and autoimmune disorders. In the past, such cases have been diagnosed as lymphoplasmacytic lymphoma. BM involvement was present in all patients. Successive biopsies showed progression and, after chemotherapy, a slight decrease in infiltrates. Transformation into DLBCL occurred in 11 of 34 patients. The patterns described are not specific for PSMZL and occur also in primary nodal MZL and, more rarely, in MALT-type lymphoma.

Chronic lymphoproliferative disorders: an integrated point of view for the differential diagnosis

Morphology is regarded as the principle basis for the identification of lymphoid neoplasms. Sometimes, however, it fails to discriminate among several chronic lymphoproliferative disorders (CLDs). Improved immunophenotyping has resulted in a better characterization of a number of variants of these diseases, some of which may benefit from different therapeutic approaches. In particular, the proposal of scoring systems using a panel of monoclonal antibodies (MoAbs) has represented a critical step in this field. In fact, to date, some MoAbs (CD5, CD23, FMC7, CD22, CD79b, and surface immunoglobulin density) are able to distinguish among several entities, thus allowing for a correct diagnosis in the majority of cases. However, there is still a small percentage of patients where the combined diagnostic approach (morphology and immunophenotyping) should be further refined by other techniques, such as cytogenetic and molecular characterization. Here numerous questions are raised indicating the need to more accurately differentiate the disease entities under discussion and better understand some of their clinical manifestations.

Serological similarities between hyperreactive malarial splenomegaly and splenic lymphoma in west Africa

In West Africa hyperreactive malarial splenomegaly (HMS) and splenic lymphoma with villous lymphocytes (SLVL) are demographically and clinically indistinguishable. Determination of lymphocyte clonality is needed to differentiate clearly between these 2 disorders. To obtain evidence to support our hypothesis that HMS and SLVL are aetiologically related we studied the serological profile of malaria-related antibodies in HMS and SLVL in West Africa. We found that in SLVL total immunoglobulin M and antimalarial antibody levels were markedly raised, a combination which is characteristic of HMS. These findings strongly support a developmental relationship between HMS and SLVL in tropical Africa and implicate malaria in this process.

Splenic lymphoma with villous lymphocytes showing del(7) and inv(10)

A 49-year-old woman presented with splenic lymphoma with villous lymphocytes (SLVL) that showed a clonal abnormality of del(7)(q22q32) in addition to inv(10)(p13q23), the latter being a previously undescribed abnormality in chronic lymphoproliferative disorders. A review of the literature on cytogenetic abnormalities of SLVL indicates that del(7q) is strongly associated with SLVL and may be important in the pathogenesis of this disorder.

Hairy cell leukemia and allied chronic lymphoid leukemias: current knowledge and new therapeutic options

This review deals mainly with the essentials of hairy cell leukemia (HCL) detailing clinical aspects, laboratory findings and morphology. Rare manifestations of HCL are listed. Newer aspects relating to cytokines, soluble interleukin receptors and TNF are reviewed. Differential diagnosis including HCL-variant, SLVL, PLL and CLL/PLL are discussed. Prognostic factors and in particular therapeutic aspects are detailed with particular emphasis on the new purine analogues Pentostatin and 2-CdA. A list of suggested reading is offered.

Immunoglobulin gene polymerase chain reaction to distinguish hyperreactive malarial splenomegaly from 'African' chronic lymphocytic leukaemia and splenic lymphoma

Hyperreactive malarial splenomegaly (HMS) is found in geographical association with B cell lymphoproliferative disorders such as 'African' chronic lymphocytic leukaemia (CLL) and splenic lymphoma with villous lymphocytes (SLVL). It is sometimes not easy to make a differential clinical diagnosis between these conditions. We have previously used Southern blotting as a definitive method for the diagnosis of monoclonal lymphoproliferation in these disorders, but this is expensive, lengthy and technically difficult. In the present paper we have compared Southern blotting with polymerase chain reaction (PCR) amplification of the immunoglobulin heavy chain gene. We found an excellent correlation between the 2 methods in demonstrating monoclonal populations of lymphocytes in patients with a clinical diagnosis of CLL or SLVL. We have further demonstrated monoclonality in a patient who could not be classified as CLL or SLVL on clinical criteria alone. In contrast, patients with well defined HMS or with non-B cell proliferations all showed polyclonal rearrangements. We propose that the immunoglobulin gene PCR is a useful tool for the investigation of tropical splenomegaly of uncertain origin.

Establishment and characterization of a villous lymphoma cell line from splenic B-cell lymphoma

A new B-cell line (VL51) with cytoplasmic villi was established from a female patient with splenic lymphoma with circulating villous lymphocytes (SLVL). The patient exhibited a clinical picture characteristic of SLVL, including massive enlargement of the spleen. Tartrate-resistant acid phosphatase (TRAP)-negative villous lymphocytes were seen in the peripheral blood, bone marrow (BM) and both red and white pulps of the spleen. Monoclonality of the VL51 cell line was confirmed by clonal genotype abnormalities in the immunoglobulin heavy chain (IgH) gene and the T-cell receptor beta (TCR beta) gene. Evidence for commitment of phenotype of the VL51 cell line to the B lineage was also shown by the immunophenotype, including expression of CD10, CD19, CD20 and surface immunoglobins. The VL51 cells were positive for Epstein-Barr virus nuclear antigen (EBNA). The VL51 cell line is the first SLVL cell line to be established, and it is expected to be useful in clarifying the leukemogenesis of SLVL.

Dual rearrangement of immunoglobulin and T-cell receptor genes in a case of splenic lymphoma with villous lymphocytes

We report here a case of "splenic lymphoma with villous lymphocytes" (SLVL) which exhibited both B- and T-cell phenotypes and genotypes. The patient was a 73-year-old man. Physical examination revealed splenomegaly and lymphadenopathy. The white blood cell count was 55.2 x 10(9)/L with 70.5% atypical lymphocytes, having cytoplasmic villi, characteristic of SLVL. The atypical cells infiltrated both the red and white pulps. Immunological analysis of the peripheral leukocytes showed both B- and T-cell phenotypes (CD5,CD11c,CD19,CD20,HLA-DR, SmIgM and lambda positive). DNA analysis revealed a dual rearrangement of the immunoglobulin heavy chain gene and T-cell receptor beta gene. SLVL has been identified as a B-cell leukemia with a relatively benign clinical course. This case had both B- and T-cell pheno- and genotypes with a progressive course. To the best of our knowledge, no case of SLVL with dual genotypes has ever been reported.

Chronic lymphocytic leukemia: present status

Chronic lymphocytic leukemia (CLL) is the form of leukemia which occurs most frequently in Western countries. Its etiology is unknown, and no relationship with viruses or genes has been demonstrated. Epidemiological data suggest that genetic and ambiental factors might be of some significance. Clinical features of CLL are due to the accumulation of leukemic cells in bone marrow and lymphoid organs as well as the immune disturbances that accompany the disease. The prognosis of patients with CLL varies. Treatment is usually indicated by the risk of the individual patient, which is clearly reflected by the stage of the disease. In the early stage (Binet A, Rai O) it is reasonable to defer therapy until disease progression is observed. By contrast, because their median survival is less than five years, patients with more advanced stages require therapy. For almost 50 years, no major advances in the management of CLL, which has revolved around the use of alkylating agents, have been made. In recent years, the therapeutic approach in patients with CLL has changed as a result of the introduction of combination chemotherapy regimens and, in particular, purine analogues. The latter are already the treatment of choice for patients not responding to standard therapies, and their role as front-line therapy is being investigated. Bone marrow transplants are also being increasingly used. It is to be hoped that in years to come the outcome of patients with CLL will be improved by these advances.

Leukemic meningitis in a patient with splenic lymphoma with villous lymphocytes (SLVL). Meningitis as a possible initial manifestation of SLVL

BACKGROUND

Splenic lymphoma with villous lymphocytes (SLVL) is a low grade, non-Hodgkin's lymphoma with a stable or slowly progressive clinical course. To the authors' knowledge, central nervous system involvement has not been described previously in patients with SLVL.

METHODS

Morphologic, immunocytochemical, and immunohistochemical analyses were conducted to determine the nature of villous lymphocytes in the peripheral blood, spleen, and cerebrospinal fluid (CSF) of a patient with massive splenomegaly.

RESULTS

A diagnosis of SLVL was made, based on tartrate-resistant acid phosphatase-negative peripheral villous lymphocytosis with CD19+, CD20+, HLA-DR+ phenotypes, and the involvement of spleen white pulp with these cells. Mononuclear cells in the CSF showed the same morphologic and immunocytochemical features seen in the villous lymphocytes in the peripheral blood and spleen. Splenectomy and intrathecal chemotherapy were successful in clearing leukemic cells from the CSF.

CONCLUSION

In this patient with SLVL in whom leukemic meningitis developed, meningitis was found to be a possible initial manifestation of SLVL.

Chronic lymphoproliferative disorders: classification and diagnosis

The chronic lymphoproliferative disorders are morphologically, immunologically and clinically heterogeneous. Common features of these processes include T, B or natural killer cell immunophenotypes and terminal deoxy-nucleotidyl transferase negativity. The B cell lymphocytic disorders include B-chronic lymphocytic leukaemia, B cell prolymphocytic leukaemia, chronic lymphocytic leukaemia-prolymphocytic leukaemia, non-Hodgkin's lymphoma (including mantle cell lymphoma) in leukaemic phase, hairy cell leukaemia and splenic lymphoma with villous lymphocytes. The T cell chronic lymphoproliferative disorders include prolymphocytic leukaemia, adult T cell leukaemia-lymphoma, large granulated lymphocyte leukaemia and Sézary syndrome. Occasionally, a lymphocytic proliferation is encountered that does not satisfy the morphological or immunophenotypical criteria for any of the above categories. These processes are best left unclassified.

Splenectomy in lymphoproliferative disorders: a report on 70 cases and review of the literature

Between February, 1970 and September, 1991, we performed splenectomies on 70 patients with chronic lymphoproliferative disorders including primary leukemias: 19 B-cell chronic lymphocytic leukemia, 1 B-cell prolymphocytic leukemia, 22 hairy cell leukemias, 4 large granular lymphocytic leukemias, 1 T-cell prolymphocytic leukemia, and non-Hodgkin's lymphomas (NHL): 10 splenic lymphomas with villous lymphocytes, 4 follicular lymphomas, 5 mantle cell lymphomas, 3 lymphoplasmacytic and 1 large cell NHL. The primary indications for surgery in this series were therapy-resistant disease (40%) and therapeutic splenectomy (38%). Postsplenectomy, 70% of patients had a complete hematological response, 23% had a partial response, and 7% were nonresponsive. Median treatment-free survival correlated with the hematologic response postsplenectomy and the underlying diagnosis. Better treatment-free survivals were seen in patients with lesser degrees of anemia and thrombocytopenia. Overall, improvements were more pronounced in the B-cell than in the T-cell disorders. Indications for further therapy, postoperative morbidity and mortality, and survival times are discussed along with a review of the literature. These findings advocate a continuing role for splenectomy in symptomatic lymphoid malignancies running with splenomegaly and hypersplenism.

Myelomonocytic antigens are rarely expressed on B-lymphocytic leukemia cells

In the light of recent observations reporting that B-lymphocytic leukemia (B-CLL) cells may express a variety of myelomonocytic antigens, 28 patients with B-CLL and B-leukemic lymphocytic lymphoma were studied for the presence of these antigens using monoclonal antibodies to detect CD13, CD33, CD15 and CD14. Analysis of immunofluorescence (IF) was carried out by two procedures; one which employed the standard conventional method of gating used in our laboratory for flow cytometry, while the other procedure increased the sensitivity of the analysis, by moving the marker for IF to the left, so as to widen the gate to include more cells with low IF. Using the conventional methodology, the mean proportion of cells considered positive was less than 3% for any of the 4 markers studied. In only a few patients were 5% or more of the B-CLL cells positive for some of the markers studied (3 patients with 6.2-11.3% CD13+; 2 with 6.0-9.6% CD14+, and one with 11.8% CD15+ cells). No case had more than 2.5% + CD33+ cells. The second procedure with a wider gate to enhance sensitivity for less positive cells, increased the number of positive cells for any of the markers in only 4 patients. These results are contradictory to others reported recently, and some of the possible causes for this discrepancy are discussed. It is suggested that more useful data may be obtained if the level of staining intensity and patterns of positive staining are documented in the future.