Diagnosis of lymphoproliferative disorders: experience of a single institution in the long-term follow-up of discordant cases

OBJECTIVE

To evaluate the usefulness of morphologic diagnosis, immunophenotyping and immunoglobulin (Ig) and T-cell receptor (TcR) gene rearrangement studies in the diagnosis of lymphoproliferative disorder.

DESIGN

A retrospective cohort study with clinical follow-up of controversial cases.

SETTING

Single institution, tertiary care centre.

PATIENTS

All 273 patients whose lymphoid tissue samples were sent for molecular analysis by Southern blotting over a 4-year period.

INTERVENTIONS

Patient reports were retrieved from the laboratory data system. Repeat assessment and clinical follow-up was done for discordant cases.

OUTCOME MEASURES

Correlation between morphologic features and the results of immunophenotype and gene rearrangement studies of the samples. Value of the different tests in discordant cases.

RESULTS

The 273 samples included 130 of non-Hodgkin's lymphoma (NHL), 23 of Hodgkin's disease, 80 of benign lymphoid hyperplasia, 16 of atypical lymphoid hyperplasia and other diagnoses. Of the 130 NHL cases diagnosed by morphologic study, 22 (17%) did not show gene rearrangement. Of the 80 morphologically benign samples, 4 (5%) showed gene rearrangement, and malignant disease developed later in those patients. Five (31%) of the 16 cases of atypical lymphoid hyperplasia showed gene rearrangement. Six of the remaining 11 cases had no detectable gene rearrangement, but hematologic malignant disease developed. No gene rearrangement was detected in Hodgkin's disease samples. One carcinoma showed gene rearrangement. Of the NHL group, 86% of the B cells and 50% of the T cells showed gene rearrangement. Seven samples showed both Ig and TcR gene rearrangement.

CONCLUSIONS

Gene rearrangement analyses correlate highly with conventional morphologic diagnosis and phenotyping. The detection of gene rearrangement in lymphoid tissue has a high specificity (99%) and a reasonable sensitivity (83%) to the development of a lymphoproliferative disorder.

Prolonged complete remission of myelodysplastic syndrome treated with danazol, retinoic acid and low-dose prednisone

Myelodysplastic syndrome (MDS) is a diverse group of clonal hematologic neoplasms. Different medications have been tried in MDS; however, no effective treatment has been yet established. We report a patient with MDS who achieved a complete remission in response to combination therapy of danazol, retinoic acid, and prednisone. A 53-year-old female presented with pancytopenia, macrocytosis, and hypercellular bone marrow with erythroid hyperplasia and dysplasia and 10% ringed sideroblasts. Cytogenetic studies revealed the presence of two abnormal clones. She was diagnosed as having MDS-refractory anemia and was given blood transfusions to maintain blood cell counts at acceptable levels. At the same time, she was started on a combination of danazol (600 mg/day), retinoic acid (100 mg/day), and prednisone (10 mg every other day). Fourteen months later, the patient was in complete hematologic remission; she had normal peripheral blood count, and the blood smear showed normal morphology. Bone marrow studies revealed normal trilineage hematopoiesis. She was continued on the same combination treatment for 86 months, and she remained in complete clinical remission. Eighty-eight months from diagnosis, she relapsed with acute myeloid leukemia. This is the first reported case of MDS-RA that sustained a complete hematologic remission for a prolonged period in response to this combination treatment. This report indicates that restoration of normal hematopoiesis, prolongation of disease-free survival, and delay in the transformation to acute leukemia may be achieved by this combination of treatment in a subset of patients with MDS, especially refractory anemia with severe thrombocytopenia.

Normal CD5+ B lymphocytes are poor stimulators in the autologous mixed lymphocyte reaction (AMLR)

The AMLR is decreased in chronic lymphocytic leukaemia (CLL), which is characterized by a monoclonal expansion of CD5+ B lymphocytes. Since B cells are used to stimulate the AMLR, we investigated the capacity of normal CD5+ B cells to function as stimulators in the AMLR. We isolated B cells from the peripheral blood of normal individuals and fractionated them into subpopulations enriched for CD5+ and CD5- cells, which were used as stimulators in the AMLR. We found that the CD5- B cells were excellent stimulators, whereas stimulation of AMLR by B cells enriched for CD5+ cells resulted in significantly reduced proliferative responses (P < 0.005). This suggests that the reduced AMLR in CLL is due to the predominance of CD5+ B lymphocytes in the stimulating cell population.

The use of toads (Bufo regularis) in a new biological assay for screening chemicals or drugs which induce leukaemia in man

Injection of Egyptian toads Bufo regularis, with adriamycin subcutaneously in the dorsal lymph sac at a dose level of 0.1 mg/toad, once every 3 weeks for 3 months induced pronounced alterations in the blood cells. These alterations were more or less similar to the criteria reported in human leukaemia. These changes were all comparable to those observed after the treatment of the experimental animals with the chemical carcinogen 7,12-dimethylbenz(a)anthracene. It is speculated that toads (Bufo regularis) can be used as biological test animals for screening chemicals or drugs which induce leukaemia in man.

Adverse drug reactions and drug substitution in an arrhythmia clinic

OBJECTIVE

To assess the impact of adverse drug reactions on antiarrhythmic drug substitution in ambulatory patients.

SETTING

Tertiary care dysrhythmia clinic.

PATIENTS AND METHODS

A total of 671 medical records were reviewed. Sex of the study population was equally distributed, with an average age of 53 years. Follow-up averaged 26 months for patients seen more than once. Suspected adverse drug reactions and substitution of antiarrhythmic agent were used to ascertain events in patients' charts. Patients were exposed to 1253 treatment courses. The number of successive antiarrhythmic agents per patient averaged 1.8 and varied from one to seven.

RESULTS

One hundred and thirty-nine (20%) patients experienced a total of 194 adverse events (15.5% of drug courses), of which only eight (4%) were serious. Ninety-four per cent of the mostly benign adverse drug reactions were followed by a therapeutic modification: discontinuation or replacement in 87% and dosage reduction in 7%. The influence of successive drug changes was evident: the risk of a reaction was 7% in patients exposed to one agent compared with 100% in patients exposed to a seventh agent.

CONCLUSIONS

First, therapeutic substitution in response to adverse drug reactions appears to be determined more by the combined expected benefit, the product of arrhythmia severity and drug efficacy, than by the severity alone of the adverse reaction; and second, the probability of an adverse drug reaction is proportional to the number of agents tried consecutively, possibly as a result of patient selection, drug selection and increased patient and doctor awareness.

Chemopreventive effects of cabbage on 7,12-dimethylbenz(a)-anthracene-induced hepatocarcinogenesis in toads (Bufo viridis)

Hepatocellular carcinoma was induced in the toad, Bufo viridis, in 29 out of 100 cases by the administration of 0.5 mg of 7,12-dimethylbenz(a)anthracene (DMBA)/toad, 3 times/week for 12 weeks. In contrast, toads treated with DMBA and cabbage diet 1 or 2 ml (3 h prior to the carcinogen)/toad, every day for 12 weeks showed a lower incidence of liver tumors: 15 and 12 cases out of 100. However, cabbage diet (2 ml/toad, every day for 12 weeks) was ineffective when administered 3 h after the carcinogen (DMBA) in 27 out of 100 cases. Neither tumor growth nor neoplastic changes were observed in toads treated with olive oil alone or with cabbage diet. It is concluded that a cabbage diet during initiation has an inhibitory effect on hepatocarcinogenesis in toads.

Amiodarone-induced epididymitis: report of a new case and literature review of 12 cases

OBJECTIVE

To report a new case and review the literature of amiodarone-related epididymitis to improve knowledge of the clinical characteristics of this reaction.

DESIGN

Cohort study.

SETTING

Tertiary out-patient arrhythmia clinic.

PATIENTS

Males currently treated for arrhythmias with amiodarone for at least two months. Thirty-two patients were identified and all were contacted.

OUTCOME MEASURES

Swelling and or/pain in the scrotum with confirmation of noninfectious epididymitis by a urologist.

DATA SOURCES

Bibliography (Medline and Embase) and databases (Manufacturer, Health Protection Branch, World Health Organisation).

STUDY SELECTION

Four articles with case reports. Databases searched for these key words: amiodarone and epididymitis.

RESULTS

A new case is reported. Twelve cases have been presented individually and six more described collectively. Times to onset range from four to 71 months, daily doses range from 200 to 800 mg. The reaction is self-limited, with or without amiodarone reduction, and does not require antimicrobial drugs, but a noninvasive urological examination may be warranted.

CONCLUSION

Awareness by cardiologists will prevent unnecessary invasive urological investigations or antibiotic therapy.

Alpha-ecdysone, a new bracken fern factor responsible for neoplasm induction in the Egyptian toad (Bufo regularis)

Neoplastic lesions were induced in 10 out of 58 experimental toads (Bufo regularis) force-fed with alpha-ecdysone, which naturally occurs in the leaves of bracken fern (Pteris aquilina). The results of this study prove that alpha-ecdysone may be one of the factors responsible for the carcinogenicity of bracken fern plant fed to cattle and other experimental animals.