A multimodal approach in the diagnosis of patients with hematopoietic disorders

Myelodysplastic syndromes (MDS) are a group of relatively ill-defined hematopoietic disorders in which both qualitative and quantitative defects of the hematopoietic cells cause bone marrow dysfunction. With an incidence estimated to be approximately 1 per 100,000 persons per year, MDS mainly affects the elderly. Myelodysplastic syndromes share many features with acute nonlymphocytic leukemia; in fact, a proportion of patients with MDS eventually develop acute myeloid leukemia. To illustrate a multimodal approach in the diagnosis of patients with hematopoietic disorders, we describe a 66-year-old patient with a question of myelodysplastic syndrome, leukemia, and two translocations involving chromosome 10:t(5;10) and t(7;10). These structural rearrangements effectively gave rise to monosomy for part of the long arm of chromosome 5 and for the long arm of chromosome 7. Findings of del(5q) and del(7) in MDS have been reported in the literature. The results of chromosome morphometry, which was conducted to compare the lengths of all relevant chromosome segments, are consistent with the hypothesized chromosomal abnormalities. The investigational technique of fluorescence in situ hybridization (FISH), using both painting and alpha-satellite probes, was used as an adjunct to conventional cytogenetics to further delineate the nature of the chromosome abnormalities observed in the GTG-banded studies. Confirmatory studies utilizing the new technique of spectral karyotyping (SKY) were also carried out. Thus, the multimodal approach of hematopathology, GTG-banding, chromosome morphometry, FISH, and SKY can be very useful for delineating complex cytogenetic cases.

Splenic marginal zone cell lymphoma associated with clonal B-cell populations showing different immunoglobulin heavy chain sequences

Splenic marginal zone cell lymphomas (SMZCLs) are low-grade B-cell lymphomas that usually present with massive splenomegaly and subtle (subleukemic) peripheral blood involvement. Polymerase chain reaction (PCR) analysis of peripheral blood from a patient with subleukemic SMZCL showed evidence of two clonal immunoglobulin heavy chain (IgH) gene rearrangements. IgH PCR analysis of DNA derived from the patient's splenic neoplasm demonstrated a single clonal IgH rearrangement, which had a different electrophoretic mobility from either of the two PCR products detected in the patient's peripheral blood. Additional characterization of these PCR products by DNA sequencing demonstrated two independent IgH rearrangements in the peripheral blood, one of which used IgH joining region 6c (JH6C) and the other JH4. A different IgH rearrangement was present in the splenic tumor, which used JH4a. No sequences from the splenic neoplasm were detected in the peripheral blood and vice versa. This case illustrates that PCR might reveal monoclonal populations in peripheral blood unrelated to the presence of lymphoma in other anatomic compartments.

Angiocentric T-cell lymphoma presenting as lethal midline granuloma

BACKGROUND

Lethal midline granuloma (LMG) is a rare condition characterized by rapidly progressive midfacial destruction. Most LMG cases are angiocentric T-cell lymphomas and an association with Epstein-Barr virus (EBV) has been reported. Cutaneous involvement is poorly described and the prognosis not well documented.

METHODS

We report a case of angiocentric T-cell lymphoma of the palate that presented as LMG with concurrent discrete skin lesions composed of two distinct morphologic appearances: indurated nodules and annular plaques. The English language literature for LMG-type angiocentric T-cell lymphoma is reviewed and a survival analysis of 58 cases with follow-up data (including our own case) is performed.

RESULTS

The 1- and 5-year survival rates were 45% +/- 7% and 22% +/- 9%, respectively. Poor survival was associated with advanced age and stage. EBV DNA was detected in 16 out of 21 reported cases in which it was sought (including our case).

CONCLUSIONS

We present photographic documentation of a broader spectrum of cutaneous lesions in the LMG-type angiocentric T-cell lymphoma than has previously been described, and have confirmed the association with EBV. The prognosis is poor. Aggressive therapy such as bone marrow transplantation should be considered early in the course.

P53 expression in Reed-Sternberg cells does not correlate with gene mutations in Hodgkin's disease

Immunohistochemically detectable p53 protein expression is common in the Reed-Sternberg and Hodgkin's (RS-H) cells of Hodgkin's disease, but p53 gene mutations have only rarely been identified. The authors found p53 expression in RS-H cells in 16 of 30 cases of Hodgkin's disease (53%), with the percentage of RS-H positive cells ranging from 4% to 85%. In 12 of 30 cases (40%), at least 10% of the RS-H cells were positive for p53. p53 gene mutations were detected in only two cases (7%) using a single-stranded conformational polymorphism assay with a detection sensitivity of between 1% and 5%. The cellular protein, mdm-2, which can stabilize and functionally inactivate wild-type p53 protein, was expressed in RS-H cells in most of these cases (86%). However, neither case with a p53 gene mutation expressed mdm-2 (P < .005). The two cases with p53 gene mutations had a higher mean proliferative index than cases without detectable mutations (90% versus 72%; P < .02). p53 expression in RS-H cells may be related to concurrent mdm-2 protein expression and a p53-positive, mdm-2-negative immunophenotype may be predictive of gene mutations in RS-H cells.

Zoonotic Brugian lymphadenitis. An unusual case with florid monocytoid B-cell proliferation

Human infection with a zoonotic Brugia species in the United States is uncommon. Positive identification of the filarial nematode is required for histopathologic diagnosis. Many cases may go unrecognized because of the nonspecific clinical manifestations and the nondiagnostic histologic changes occurring in involved lymph nodes. A case of zoonotic Brugia lymphadenitis is described in a patient from Rhode Island, in which a small nongravid female worm was identified in a lymph node biopsy specimen. The lymph node also showed a spectrum of reaction changes including the presence of florid monocytoid B-cell proliferation, which has not been described in association with zoonotic Brugian filariasis.

Lymphoma of the mucosa-associated lymphoid tissue of the lung. A multifocal case of common clonal origin

Low-grade B-cell lymphomas of the mucosa-associated lymphoid tissue (MALT) are extranodal tumors that tend to be localized. In this case report, the authors describe an unusual multifocal pulmonary MALT lymphoma, which presented radiologically as three discrete lesions involving two separate lobes of the lung, in addition to numerous separate macroscopic and microscopic foci of disease. The lesions were composed of centrocyte-like cells and cytologically bland plasma cells surrounding reactive lymphoid follicles with focal areas resembling lymphoid interstitial pneumonia (LIP). Immunohistochemical studies demonstrated a predominance of immunoglobulin kappa light chain positive plasma cells in the largest lesion. A polymerase chain reaction (PCR) assay demonstrated conserved immunoglobulin heavy chain gene rearrangements in the large tumor nodules as well as microscopic foci resembling LIP. This case illustrates the utility of PCR for identifying the clonal nature of lymphoid lesions that are too small or heterogeneous to unequivocally assess by other means.

Malignant carcinoid of the pancreas: a cytologic, ultrastructural, and immunocytochemical study of a case diagnosed by fine-needle aspiration of a supraclavicular node metastasis

Carcinoid tumor of the pancreas is extremely rare. This article describes the case of a 22-year-old woman who manifested a typical carcinoid syndrome; a definitive diagnosis of a metastatic carcinoid tumor was made from needle aspiration of a supraclavicular lymph node using morphologic, immunocytochemical, and ultrastructural criteria. The carcinoid tumor was subsequently shown to be of pancreatic origin.

Oat cell carcinoma of the urinary tract. An immunohistochemical and electron microscopic study

Four oat cell carcinomas of the urinary tract (three of the bladder and one of the ureteropelvic junction) were studied using immunohistochemical and electron microscopic methods to evaluate the possible histogenesis of these tumors. Ultrastructurally, the oat cell component of the tumors had neurosecretory-type granules and positive immunoreaction for neuron-specific enolase, indicating the endocrine nature of the tumors. Three tumors were mixed with a non-oat cell component: adenocarcinoma and/or transitional carcinoma or carcinoid tumor. There are no previous reports of mixed oat cell and adenocarcinoma or carcinoid tumor of the urinary tract. This report is also the first of an oat cell carcinoma originating in the pelvic ureteric junction.

Desmoid fibromatosis: a clinicopathologic study of 25 children

We studied 25 patients under 15 years of age with desmoid fibromatosis (DF). There were 15 boys and 10 girls; 13 were under seven years of age and 12 were above. Histologically, DF was identical to DF in adult patients, except for a higher mitotic rate in children's tumors. The tumors were located on the head and neck (8), upper (7) or lower (6) extremities, or the trunk (4). Patients with head and neck DF received preoperative adriamycin and 5-(dimethyltriazeno) imidazole-4-carboxamide or a combination of vincristine, actinomycin D, and cyclophosphamide. In seven patients, tumor reduction began to occur during chemotherapy, while in one patient, there was no response at all. Five patients underwent conservative resections of their residual tumors, and in two patients, all tumor disappeared necessitating no additional surgery. Follow-up in these patients indicates that 6 have no evidence of disease, 1 is alive with recurrent disease, and 1 is lost to follow-up. Surgery was the primary modality of treatment for the trunk and extremity lesions. Twelve patients had no evidence of disease from 2 months to 25 years and 5 months, two died from complications of chemotherapy, and three were lost to follow-up. Our experience agrees with that of other investigators that DF is best managed surgically. However, preoperative chemotherapy should be strongly considered for patients with tumors occurring in the head and neck areas.

Desmoid tumors and their management

Nineteen cases of desmoid tumors were reviewed, being intraabdominal. Five of the 7 were associated with polyposis coli. The remaining 12 cases were distributed in different anatomic locations. Sixteen patients were treated with resection either alone or in combination with radiation or hormonal treatment. There were two deaths due to unrelated causes, and the rest of the patients (89 percent) are alive. At present, 16 of the surviving 17 patients are disease-free with a mean follow-up of 6 years. In two of eight patients who were initially treated with wide excision at our center, local recurrence developed, and five patients treated with resection elsewhere were referred because of recurrence. Six patients treated with simple resection and adjuvant radiation remain free of disease with a mean follow-up of 5 1/2 years.

Congenital alveolar capillary dysplasia: a developmental vascular anomaly causing persistent pulmonary hypertension of the newborn

The clinical course and histologic findings are presented of an infant with an unusual form of pulmonary dysplasia. Characteristic sonographic findings and progressive hypoxemia led to the diagnosis of persistence of the fetal circulation. The patient expired despite ventilatory and pharmacologic intervention. Postmortem findings of severe pulmonary capillary hypoplasia, despite normal anatomical and biochemical parenchymal maturation, were observed. It is suggested that factors controlling pulmonary capillary maturation may be significantly different from those involved in airway and pulmonary parenchymal development.