T lymphocyte proliferation in lymphomatoid granulomatosis

Proliferation and cellular phenotype in lymphomatoid granulomatosis: implications of a higher proliferation index in B cells

Pulmonary involvement by lymphomatoid granulomatosis (LYG) is characterized by nodules of a polymorphous lymphoreticular infiltrate with necrosis, angioinvasion, and variable numbers of large, atypical cells. Using combined immunohistochemistry, the authors compared the expression of a marker of proliferation (DNA topoisomerase IIalpha) between B cells, T cells, and histiocytes. Sixteen cases of LYG were stained by combined immunohistochemistry for DNA topoisomerase IIalpha and CD-20, CD-3, CD-68, and CD-57. A proliferation index was determined for B cells, T cells, histiocytes, and natural killer cells by dividing the number of cells with coexpression of DNA topoisomerase IIalpha and CD-20, CD-3, CD-68, or CD-57 by the total number of CD-20+, CD-3+, CD-68+, or CD-57+ cells, respectively. A significantly higher proliferation index was present in B cells compared to T cells, histiocytes, or natural killer cells (p < 0.002). The average proliferation index for B cells was 0.25+/-0.24 (range, 0.00-0.76), for T cells was 0.02+/-0.01 (range, 0.00-0.04), for histiocytes was 0.00+/-0.01 (range, 0-0.02), and for natural killer cells was 0.00+/-0.00 (range, 0.0-0.02). The average proliferation index of CD-20+ cells was greater in grade III LYG (0.36) than in grade II LYG (0.17) or the single case of grade I LYG (0.00). The authors conclude that (1) there is a spectrum of B-cell proliferation in LYG that roughly correlates with histologic grade, (2) T cells, histiocytes, and natural killer cells do not proliferate but are recruited, and (3) the average B-cell proliferation index in grade III LYG is similar to that observed in large cell non-Hodgkin's B-cell lymphomas. These observations provide a possible rationale for the use of chemotherapy for grade III LYG and observation or immunologic adjuvants for LYG with grade I or grade II histology.

Isolated cerebellar lymphomatoid granulomatosis progressing to malignant lymphoma. Case report

A 60-year-old man presented with progressive and unique neurological symptoms. Investigations identified an isolated cerebellar lesion. This lesion fulfilled the histological criteria for lymphomatoid granulomatosis, and in situ hybridization and deoxyribonucleic acid (DNA) dot blot techniques revealed significant amounts of Epstein-Barr virus DNA within the tumor cells. The patient underwent cranial radiation therapy, and 16 months after the initial presentation the lesion evolved into a malignant lymphoma. He subsequently died secondary to subdural empyema, bacterial meningitis, and bronchopneumonia. The unique clinical and etiological aspects of this case are addressed.

Epstein-Barr virus-associated primary B-cell lymphoproliferative disorder of the cerebellum in an immune competent man

BACKGROUND

The role of the Epstein-Barr virus (EBV) in lymphoproliferative lesions has been widely accepted. Most of these lesions occur in patients who have deficiencies in their immune status. Lymphomatoid granulomatosis (LG) is a lymphoproliferative disorder originally characterized as an angiocentric, necrotizing, pleomorphic infiltrate of mononuclear cells. The etiology of LG is unknown. It was originally hypothesized that LG may represent an unusual lymphoid response to an infective organism, possibly EBV.

METHODS

Tissues from a previously healthy 60-year-old, healthy white man with primary cerebellar lymphomatoid granulomatosis were examined for the presence of EBV by nucleic acid hybridization.

RESULTS

The original LG lesion was a polyclonal B-cell proliferation that contained detectable amounts of EBV. Peripheral blood leukocytes were negative for EBV by the same assay. After an 18-month remission, a tumor reappeared near the site of the primary lesion, which had the histologic appearance of a lymphoma. The cells showed restricted clonality and contained a similar amount of EBV-related DNA as the original lesion. Peripheral blood leukocytes at the time of recurrence were negative for EBV. The patient died approximately 2 months after the recurrent tumor was detected.

CONCLUSIONS

This case demonstrated the development of a primary cerebellar B-cell lymphoproliferative disorder, histologically identical to lymphomatoid granulomatosis, that transformed into a lymphoma. The original tumor and the subsequent lymphoma contained, on average, several copies of EBV-related DNA per cell. Despite an extensive survey of the patient, no immune deficit was detected. Interpretation of the literature with the results of this case suggest that this instance of primary cerebellar LG arose as a consequence of an unusual EBV-associated B-cell lymphoproliferation. It is suggested that EBV may be a significant factor in the initiation of the abnormal proliferations of T-cells or B-cells reported in this disorder.

Pulmonary lymphomatoid granulomatosis in seven dogs (1976-1987)

Seven dogs with pulmonary lymphomatoid granulomatosis were reviewed. The disease occurred in six large-breed and one small-breed dogs. The dogs were five to 14 years old (mean, 8.4; median, 7), and four of seven dogs were males. Three dogs had been previously treated with adulticide therapy for canine dirofilariasis. Clinical histories included a progressive respiratory disease characterized by varying degrees of cough, dyspnea, exercise intolerance, and weight loss. Thoracic radiographic features included hilar lymphadenopathy, pulmonary masses of varying sizes, and mixed pulmonary patterns of lobar consolidation with ill-defined interstitial and alveolar pulmonary infiltrates. Cardiovascular changes compatible with chronic dirofilariasis were present in three dogs. The clinical course was usually progressive and fatal. The survival time ranged from six days to four years (mean, 12.5 mos; median, 3 mos). Gross and histologic features included mass lesions with areas of necrosis that replaced normal pulmonary architecture. Cytologically, these lesions were characterized by infiltration with pleomorphic, angioinvasive mononuclear cells that often resulted in vascular obliteration. The infiltrating cells resembled large lymphoid cells that possessed large hyperchromatic nuclei and small amounts of cytoplasm. Systemic lymphoid neoplasia with peripheral lymphadenopathy was diagnosed in two dogs. In both cases, lymph-node cytology was similar to the cellular infiltrates found in the lungs and consistent with a diagnosis of lymphomatoid granulomatosis. These features are compared with previously reported cases of canine lymphomatoid granulomatosis and those features identified in a similar disease described in man.

Clinical implications of the histopathologic diagnosis of pulmonary lymphomatoid granulomatosis

We reviewed the epidemiologic, laboratory, roentgenographic, pulmonary function, and survival data from 28 patients who had a histologic diagnosis of lymphomatoid granulomatosis (LG) with involvement of the lungs. The mean age at the time of diagnosis was 51 years, and the male-to-female ratio was 3:2. Ten patients had other underlying diseases before LG was diagnosed. The most prominent symptoms were cough, dyspnea, fever, and rash, which were usually present for several months before diagnosis of LG. Multiple nodules were detected on a chest roentgenogram in 68% of the patients. Immunoglobulin concentrations were abnormal in 8 of 12 patients studied. Although bronchoscopy established the diagnosis in approximately a third of the patients who underwent this procedure, open-lung biopsy was uniformly diagnostic. The median survival was 72 months, with follow-up through 12 years. In 11 patients, the original diagnosis of LG was eventually changed to lymphoma. In five of these patients, the change in diagnosis was based on immunohistologic data obtained shortly after LG was discovered. Lymphoma diagnosed in this way was associated with a better prognosis than lymphoma diagnosed on the basis of conventional histopathologic findings. In three patients, solid tumors eventually developed. The diversity of clinical outcomes and frequent revisions of the diagnosis led us to consider the possibility that LG may also represent a histopathologic finding that occurs transiently in several disease processes.

Lymphomatoid granulomatosis in a patient with acute myeloblastic leukemia in remission

In a patient treated for acute myeloblastic leukemia (AML), we saw an angiocentric and angiodestructive lymphoma that resembled lymphomatoid granulomatosis (LG). The lesions tended to involve extranodal sites such as the lung, the parotid gland, and the skin. The immunologic studies showed that the proliferating lymphoid cells were mature T cells. Furthermore, genotypic studies disclosed a clonal rearrangement of the beta T-cell receptor gene. It is concluded that this case of LG is related to a neoplastic T-cell lymphoproliferative disorder. The relations between LG and the previous AML are discussed.

Rheumatologic manifestations of malignancy

The relationship between rheumatologic syndromes and cancer covers a very broad array of both common and distinctly rare manifestations. This discussion has outlined some of the known relationships that do exist. A high index of suspicion by both the primary care physician and subspecialist will enhance the probability of detecting cancer in the patient who may present with rheumatologic complaints.

Lymphomatoid granulomatosis and malignant lymphoma of the central nervous system in the acquired immunodeficiency syndrome

While primary and secondary malignant lymphomas have been well-documented in the CNS of patients with the acquired immunodeficiency syndrome (AIDS), only one case of lymphomatoid granulomatosis (LG) involving the CNS has been reported. We present three AIDS patients with multiple grossly evident foci of necrosis in the cerebral hemispheres which, on histologic evaluation, were seen to contain angiocentric mixed chronic inflammatory infiltrates with atypical mononuclear cells, luminal thrombosis, and infarction, which is typical of LG. LG was also identified in sections of the lung in one case. Lymphoma was found in other regions of the brain in two cases, suggesting the evolution of LG into cerebral lymphoma. In addition, widespread perivascular multinucleate syncytial giant cells, associated with human immunodeficiency virus (HIV) infection of the CNS, were identified in all patients. The features of LG, its relationship to lymphoma, and the possible etiologic role of an immunodeficiency state or the HIV virus in the pathogenesis of LG are discussed.

Sequential half-body irradiation in lymphomatoid granulomatosis. Report of a case and an immunohistologic study

A case is presented of a man with ulcerating skin nodules who was diagnosed by histologic and immunohistologic analysis of skin biopsy specimens as having lymphomatoid granulomatosis (LYG). Phenotypic studies showed the majority of the infiltrating cells to be activated CD4+ T-lymphocytes. The disease followed a rapidly progressive course and did not respond to treatment with cytotoxic chemotherapy. The patient developed life-threatening systemic symptoms and involvement of both upper and lower respiratory tracts. After treatment with sequential half-body irradiation he has been in complete remission for 3.5 years.

Necrotizing vasculitis with granulomatosis

Table 1 summarizes some of the differentiating characteristics among these diseases. Clinically, the differentiating features are that classic Wegener's granulomatosis involves both the upper and lower respiratory systems and kidneys. Renal involvement is the major cause of morbidity and mortality. Churg-Strauss syndrome has the distinguishing characteristics of an allergic asthmatic prodrome and a profound eosinophilia. It encompasses and destroy's tissue not only of the lungs but also most of the other organ systems in the body. A major cause of mortality is cardiac disease, which is not a feature of either of the other two diseases. Finally, lymphomatoid granulomatosis is seen predominantly in the lungs, skin, and central nervous system and is the only one of the three that is associated with the development of a lymphoma. Although there are definitive clinical differences of these entities, as mentioned above, it is the histopathologic features that can diagnostically separate the three. Wegener's granulomatosis is predominantly a necrotizing granulomatous infiltrate that has a polymorphous infiltrate of neutrophils, plasma cells, and histiocytes and is very distinct from the eosinophilic granulomas of CSS or the lymphocytic ones of LYG. Finally, all of the diseases respond differently to medications. Patients with Churg-Strauss syndrome for the most part respond well to high dosages of oral steroids and usually do not require therapy with immunosuppressive agents. Therapy with steroids alone is not adequate for the treatment of Wegener's granulomatosis, and the therapy is a combination of steroids with chemotherapeutic agents, cyclophosphamide being the agent of choice. The most difficult disease to treat in this review is LYG.(ABSTRACT TRUNCATED AT 250 WORDS)

Lymphomatoid granulomatosis of the lung: report of a case and gene rearrangement studies

Lymphomatoid granulomatosis is an uncommon but well-described entity which is currently thought to represent either a variant of malignant lymphoma from its outset or a benign yet prelymphomatous lesion. We recently studied such a case in a 70-year-old man who presented with bilateral pulmonary nodules on chest x-ray. Open lung biopsy and wedge resection revealed the typical histologic changes of lymphomatoid granulomatosis and immunohistochemical studies demonstrated a T cell proliferation. Genetic analysis of frozen tissue by Southern blot DNA hybridization showed no evidence of rearrangements of either the T cell receptor or immunoglobulin genes. This supports the notion that at least some cases of lymphomatoid granulomatosis may be part of a spectrum of premalignant lymphoproliferative disease rather than being frank malignant lymphoma from their outset.

Pulmonary lymphoid neoplasms. Role of immunohistology in the study of cellular immunotypes and in differential diagnosis

Seven cases of lymphoid neoplasms presenting in the lung were evaluated by immunohistology for T and B cell antigens and immunoglobulin light chains in frozen tissue sections. Although follow-up was short or inconclusive in some patients with lymphoma and pseudolymphoma, it was concluded that evaluation of T and B cell antigens and immunoglobulin light chains in frozen tissue is helpful in classifying lymphocytic neoplasms, especially in cases without definite cytologic evidence of malignancy. As demonstrated in two additional cases, lymphocyte/leukocyte markers in paraffin-embedded tissue are important in the differential diagnosis of lesions with cytologic features of malignancy.