Over 30% of patients with splenic marginal zone lymphoma express the same immunoglobulin heavy variable gene: ontogenetic implications

We performed an immunogenetic analysis of 345 IGHV-IGHD-IGHJ rearrangements from 337 cases with primary splenic small B-cell lymphomas of marginal-zone origin. Three immunoglobulin (IG) heavy variable (IGHV) genes accounted for 45.8% of the cases (IGHV1-2, 24.9%; IGHV4-34, 12.8%; IGHV3-23, 8.1%). Particularly for the IGHV1-2 gene, strong biases were evident regarding utilization of different alleles, with 79/86 rearrangements (92%) using allele (*)04. Among cases more stringently classified as splenic marginal-zone lymphoma (SMZL) thanks to the availability of splenic histopathological specimens, the frequency of IGHV1-2(*)04 peaked at 31%. The IGHV1-2(*)04 rearrangements carried significantly longer complementarity-determining region-3 (CDR3) than all other cases and showed biased IGHD gene usage, leading to CDR3s with common motifs. The great majority of analyzed rearrangements (299/345, 86.7%) carried IGHV genes with some impact of somatic hypermutation, from minimal to pronounced. Noticeably, 75/79 (95%) IGHV1-2(*)04 rearrangements were mutated; however, they mostly (56/75 cases; 74.6%) carried few mutations (97-99.9% germline identity) of conservative nature and restricted distribution. These distinctive features of the IG receptors indicate selection by (super)antigenic element(s) in the pathogenesis of SMZL. Furthermore, they raise the possibility that certain SMZL subtypes could derive from progenitor populations adapted to particular antigenic challenges through selection of VH domain specificities, in particular the IGHV1-2(*)04 allele.

Somatostatin receptor activation (sst(1) -sst(5) ) differentially influences human retinal pigment epithelium cell viability

PURPOSE

To investigate the differential effects of somatostatin and its receptors (sst(1-5) ) on the viability of cultured human retinal pigment epithelium (hRPE) cells.

METHODS

MTT [3 (4, 5-dimethylthiazol-2yl)-2, 5 diphenyltetrazolium bromide], APO Percentage(TM) and trypan blue assays were performed to assess the mechanisms via which somatostatin (10(-10) -10(-4) m) and selective receptor (sst(1-5) ) ligands (10(-12) -10(-4) m) affect cell viability. The effect of orthovanadate (phosphatase inhibitor, 10(-7) -10(-5) m) on somatostatin's (10(-5) m) actions was examined, and western blot analysis was employed to determine the presence of ssts and phosphotyrosine phosphatase SHP-1 in human RPE cells.

RESULTS

Somatostatin and selective ligands for the five somatostatin receptor subtypes (sst(1-5) ) decreased cell viability in a concentration-dependent manner. The observed decrease in cell number was partly because of apoptosis via the activation of sst(1) and sst(5) receptors. Activation of sst(2) , sst(3) and sst(4) receptors led to inhibition of cell growth that did not involve apoptosis, but rather antiproliferative actions. SHP-1 was found in the human RPE cells and sodium orthovanadate reversed somatostatin's actions.

CONCLUSIONS

This study provides new information regarding the involvement of ssts in human RPE cell viability and suggests that a pathway involving the phosphotyrosine phosphatase may mediate somatostatin's actions.

Two-year results of cataract extraction with implantation of the hydrophilic acrylic B-lens

PURPOSE

To evaluate the safety and efficacy of a hydrophilic acrylic intraocular lens (B-Lens((R)), Hanita, Israel) during a 2-year follow-up period.

SETTING

Department of Ophthalmology, Meir Hospital, Sapir Medical Center, Kfar-Saba, Israel.

PATIENTS & METHODS

Slit lamp biomicroscopy, refraction, visual function and patient satisfaction were recorded in 147 patients at 1 week, and at 1, 3, 12, and 24 months after surgery.

RESULTS

Nine cases (6%) were associated with partial rupture of the superior haptic intraoperatively, which did not preclude in-the-bag centration of the IOL in all cases. Postoperative complications were mild or reversible and rarely observed. The posterior capsule opacification (PCO) rate increased considerably (from 0.35 to 0.80) from 1 to 2 years but was for the most clinically insignificant; 16 of the 90 cases (18%) with PCO at 2 years had clinically significant opacification of the posterior capsule. No IOL discoloration was observed. BCVA stabilized by the third month and refraction was at the predicted level at two years. Eighty-one of 91 cases (89%) had BCVA equal to or more than 20/40 and 43 of 91 (47%) gained a BCVA of 20/20 at two years.

CONCLUSION

Hydrophilic acrylic B-Lens((R)) implantation is safe and effective for patients with cataract.

Central retinal vein occlusion after uncomplicated glaucoma filtering procedure combined with phacoemulsification

We present a case of central retinal vein occlusion after an combined phacotrabeculectomy in a patient with advanced open angle glaucoma. Possible pathogenetic mechanisms for this complication are discussed.

Somatostatin for Uveitic Cystoid Macular Edema (CME)

PURPOSE

To report the favorable response of bilateral recalcitrant uveitic cystoid macular edema (CME) to treatment with a somatostatin analog.

METHODS

Medical ophthalmic history and the results of ophthalmic examinations were recorded. Fluorescein angiography (FA) studies were reviewed.

RESULTS

A 52-year-old white female with intermediate uveitis developed bilateral recalcitrant CME. Treatment with subcutaneous injections of the somatostatin analog octreotide resulted in partial resolution of the CME and improvement of visual acuity.

CONCLUSIONS

Somatostatin may play a role in the treatment of CME secondary to uveitis.

Splenic marginal zone lymphoma proposals for a revision of diagnostic, staging and therapeutic criteria

Since the initial description of splenic marginal zone lymphoma (SMZL) in 1992, an increasing number of publications have dealt with multiple aspects of SMZL diagnosis, molecular pathogenesis and treatment. This process has identified multiple inconsistencies in the diagnostic criteria and lack of clear guidelines for the staging and treatment. The authors of this review have held several meetings and exchanged series of cases with the objective of agreeing on the main diagnostic, staging and therapeutic guidelines for patients with this condition. Specific working groups were created for diagnostic criteria, immunophenotype, staging and treatment. As results of this work, guidelines are proposed for diagnosis, differential diagnosis, staging, prognostic factors, treatment and response criteria. The guidelines proposed here are intended to contribute to the standardization of the diagnosis and treatment of these patients, and should facilitate the future development of clinical trials that could define more precisely predictive markers for histological progression or lack of response, and evaluate new drugs or treatments.

Infliximab Therapy for the Treatment of Refractory Ocular Inflammatory Disease

OBJECTIVE

To report the outcomes of infliximab therapy in the treatment of ocular inflammatory disease refractory to traditional immunomodulatory therapy (IMT).

METHODS

We retrospectively reviewed the medical records of 27 patients. All patients had noninfectious ocular inflammatory disease refractory to traditional IMT and received 5 mg/kg of infliximab at 2-week to 8-week intervals. Main outcome measures were clinical response, reduction in concomitant IMT, and adverse effects. Cumulative incidences of inflammation control and vision change were calculated using life-table methods.

RESULTS

Twenty-one patients experienced sustained improvement in inflammation with their initial course of infliximab therapy. Cumulative incidence of inflammation resolution at 12 months was greater than 90%. Sixteen patients were able to decrease the dose of their concomitant IMT medication or stop all other IMT. Four patients were able to discontinue all other IMT while receiving infliximab therapy. Three patients with scleritis were eventually able to remain inflammation-free while not taking any medication. At 12 months, 56% and 65% of left and right eyes, respectively, showed visual acuity improvement by 2 or more Snellen lines. Only 1 patient developed an adverse event requiring therapy discontinuation.

CONCLUSIONS

We found a high rate of ocular inflammation control with infliximab therapy. The incidence of adverse effects in this study was low.

Safety and efficacy of intravitreal triamcinolone acetonide for uveitic macular edema

BACKGROUND

To evaluate the safety and efficacy of intravitreal triamcinolone acetonide (TA) for treating macular edema secondary to non-infectious uveitis.

METHODS

Retrospective review of sixteen patients (20 eyes) with chronic cystoid macular edema (CME) as a consequence of controlled intermediate uveitis, posterior uveitis, or panuveitis who received at least one intravitreal injection of TA. Main outcome measures were visual acuity (VA), intraocular pressure (IOP), formation or progression of an existing cataract, and CME resolution during the follow-up period.

RESULTS

At last follow-up, VA showed improvement (compared to baseline) in 11 eyes (55%), deterioration in three eyes (15%), remained completely unchanged in one eye (5%), and showed improvement initially but returned to baseline levels in five eyes (25%). At last follow-up, CME had relapsed or was still present in 10 of the eyes (50%). The remaining eyes showed complete resolution of the CME, without evidence of recurrence during the follow-up time. Mean VA at last follow-up showed statistically significant improvement (p = 0.02) in nonvitrectomized eyes (mean baseline VA: 1.14 +/- 0.58; mean final VA: 0.96 +/- 0.66) compared to the almost unaltered mean visual acuity for vitrectomized eyes (mean baseline VA: 0.76 +/- 0.41; mean final VA: 0.71 +/- 0.48)(p = 0.40, paired samples t-test). Elevation of IOP was transient in all cases and responded well to topical medications, except for one patient who required placement of an Ahmed valve. Preexisting cataract progressed in three of the 15 phakic eyes (20%). One patient developed a retinal detachment and required additional surgery to reattach it. Patients were followed for a mean of 34 weeks (median: 32 weeks; range: 19-56 weeks).

CONCLUSIONS

Intravitreal TA may play a role in the treatment of uveitis-related CME. Further controlled studies are necessary to test this hypothesis.

Activated T-lymphocytes with myelosuppressive properties in patients with chronic idiopathic neutropenia

To characterize the cellular components responsible for the impaired granulopoiesis in chronic idiopathic neutropenia (CIN), we investigated the origin of the proapoptotic cytokine producing cells in the bone marrow (BM) microenvironment of CIN patients. We found that the interferon gamma (IFN gamma) and/or Fas-ligand expressing cells in patient BM mononuclear cells and long-term BM culture stroma cells were the CD3(+) T-lymphocytes but not the CD14(+) monocytes/macrophages. The percentage of activated T-lymphocytes was increased in patients' BM as indicated by the proportions of human leucocyte antigen (HLA)-DR(+), CD25(+), CD38(+), CD69(+) and Fas(+) cells within the CD3(+) fraction. Intracellular IFN gamma expression was higher in the BM than peripheral blood of the patients and was associated with increased BM T-lymphocyte numbers. In crossover experiments, patient CD3(+) T-lymphocytes conferred autologous and allogeneic haemopoietic progenitor cell colony inhibition. Patients' T-cell receptor repertoire and polymerase chain reaction analysis did not reveal any clonal T-lymphocyte expansion, suggesting the absence of a direct, antigen-driven recognition of CD34(+) myeloid progenitor cells by patient T-lymphocytes. We conclude that CIN patients have increased number of activated T-lymphocytes in the BM, probably in the setting of a localized polyclonal immune reaction and that these cells confer an inhibitory effect on myelopoiesis through myelosuppressive cytokines including Fas-ligand and IFN gamma.

Ocular Cicatricial Pemphigoid, Keratomycosis, and Intravenous Immunoglobulin Therapy

PURPOSE

To report the case of a patient developing fungal keratitis in the context of uncontrolled ocular cicatricial pemphigoid (OCP), which, despite intravenous immunoglobulin (IVIg) and other immunomodulatory therapy, progressed to end-stage pemphigoid, with corneal opacification, ankyloblepharon, and xerosis. Keratoprosthesis (KPro) restored functional vision for the patient.

METHODS

A 39-year-old man presented with uncontrolled CP and corneal ulcer in the left eye. Conjunctival biopsy diagnosed OCP; corneal scraping and biopsy diagnosed the cause of the corneal ulcer. OCP was treated with systemic steroids, immunosuppressive drugs, and IVIg. Visual rehabilitation was accomplished with Ahmed valve and a type II Dohlman KPro.

RESULTS

Immunohistology of the biopsied conjunctiva showed IgG at the epithelial basement membrane zone, confirming the clinical diagnosis of OCP. Microbiologic studies of the corneal biopsy specimen were negative for Acanthamoeba and herpes but positive for Aspergillus niger. The patient's keratomycosis resolved with topical antifungal therapy. Treatment with Dapsone, intravenous-pulse steroid, oral cyclophosphamide, and intravenous immunoglobulin (IVIg) failed to control the OCP, with resultant complete conjunctivization of the cornea. Keratoprosthesis improved the patient's visual acuity from hand movements to 20/20.

CONCLUSIONS

Patients with uncontrolled OCP are at increased risk of corneal infection. The difficulty in diagnosing keratomycosis and the relatively rare occurrence of OCP explain the uniqueness of our reported case. OCP may progress to "end-stage" disease despite therapy. Keratoprosthesis can restore vision in selected otherwise seemingly hopeless cases.

Bilateral chronic anterior uveitis & neuro-ophthalmologic manifestations in a patient with Churg-Strauss syndrome: an unusual ocular presentation

We describe a patient with Churg-Strauss syndrome (CSS) who developed bilateral chronic anterior uveitis and neuro-ophthalmologic manifestations 20 years after the onset of asthma and sinus disease. The patient was treated successfully with a combination of cyclophosphamide and prednisone, after other immunomodulatory strategies, aside from systemic prednisone, had failed.

Effect of Somatostatin on Nitric Oxide Production in Human Retinal Pigment Epithelium Cell Cultures

PURPOSE

To investigate the presence of somatostatin and its receptors (sst(1-5) receptors) and their possible involvement in the regulation of nitric oxide (NO) production in human RPE cell cultures.

METHODS

Human RPE cells (D407) were used for all studies performed. Somatostatin levels were detected by radioimmunoassay, and RT-PCR and immunocytochemistry studies were performed to identify the somatostatin receptors (sst1-sst5). Radioligand binding assays were also performed examining the ability of certain somatostatin ligands (sst1, sst2, sst5) to compete for [125I]Tyr11 somatostatin binding. The presence of NO synthase in the cultures was assayed with NADPH-diaphorase cytochemistry, and RT-PCR, and NO levels were assessed by examining the production of its stable metabolites NO2- and NO3- (NOx-).

RESULTS

SRIF was detected in a concentration of 0.56 +/- 0.13 picomoles/mg protein. sst1, sst2, and sst5 mRNAs were detected, yet only sst2B and sst5 immunoreactivity was observed in human RPE cell cultures. sst1- and sst5- but not sst2-selective ligands displaced the specific [125I]Tyr11 somatostatin binding to RPE cell membranes. NADPH-diaphorase stain and iNOS mRNA were detected. SRIF and the sst2-selective analogue MK678 increased the levels of NOx- in a concentration-dependent manner. This increase was blocked by the sst2 antagonist CYN-154806 (Ac-4NO2-Phe-c(dCys-Tyr-dTrp-Lys-Thr-Cys)-dTyr-NH2).

CONCLUSIONS

These results demonstrate the presence of somatostatin, and its receptors sst1, sst2B, and sst5 in human RPE cells and suggest an autocrine or paracrine role for somatostatin. Somatostatin's ability to regulate NO production, by activating sst2 receptors, provides a functional role of somatostatin in the RPE.

The Role of Lanreotide in the Treatment of Choroidal Neovascularization Secondary to Age-Related Macular Degeneration

PURPOSE

To evaluate the role of somatostatin in the treatment of subfoveal choroidal neovascularization (CNV).

METHODS

Twenty eyes of 20 patients with CNV were included in the study. Patients were randomly allocated to treatment with lanreotide (10 eyes) or placebo (10 eyes). Patients received one intramuscular injection of lanreotide or placebo every 15 days for a total of 6 months. Follow-up lasted for 6 months for the control group and 12 months for the study group. The changes in visual acuity and fluorescein angiography at 6 months were compared between the two groups. In addition, the changes in the same parameters within the study group, from 6 to 12 months, were studied.

RESULTS

From baseline to 6 months, the mean visual acuity and surface area of hyperfluorescence remained stable in the study group, while the intensity of hyperfluorescence decreased. After discontinuation of treatment, deterioration of all three parameters was noted in the study group. Statistical analysis, however, failed to reveal any significant difference from baseline.

CONCLUSIONS

During treatment with lanreotide, a trend for stabilization of visual acuity and intensity of hyperfluorescence was documented in the study group, but it did not reach statistically significant levels. Further randomized, controlled clinical trials with larger samples and longer duration of treatment and follow-up are warranted to evaluate the role of lanreotide in the treatment of age-related CNV.

Epithelial ingrowth after laser in situ keratomileusis: a histopathologic study in human corneas

OBJECTIVE

To report the histopathologic findings in 4 human corneas that developed epithelial ingrowth after laser in situ keratomileusis (LASIK), at various postoperative intervals.

METHODS

One specimen was obtained intraoperatively during treatment of epithelial ingrowth 2 months after LASIK (case 1). The other 3 corneal specimens were obtained after penetrating keratoplasty performed at 7 months (case 2), 20 months (case 3), and 5 years (CASE 4) after LASIK. The specimens were examined with both light and transmission electron microscopy.

RESULTS

In case 1, most of the epithelial cells under the flap looked viable. However, some had begun to lose their characteristic shape and intercellular contacts. In case 2, aggregations of nonactivated fibroblasts and degrading epithelial cells could be observed. The surrounding collagen matrix differed significantly from that of the intact corneal matrix. In case 3, only completely degraded epithelial cells could be found, surrounded by collagen fibrils approximately 2 to 2.5 times larger in diameter than typical corneal collagen. In case 4, epithelial cell remnants, surrounded by a continuous layer resembling the basal membrane, were observed.

CONCLUSIONS

Corneal epithelial cells lose their characteristic morphologic features and eventually degrade in the metabolically "unusual" environment of the flap interface. Concurrently, a capsule of connective tissue similar to scar tissue forms, separating them from healthy cornea.

A unique case of splenic marginal zone-cell lymphoma with synchronous clonal T-cell large granular lymphocyte proliferation: an immunologic, immunohistochemical and genotypic study

We describe a case of synchronous splenic marginal zone-cell lymphoma (SMZL) and T-cell large granular lymphocyte leukemia involving the spleen, liver, bone marrow and peripheral blood. The synchronous occurrence of these two processes was documented by morphological, immunophenotypical and molecular (PCR) analyses of all affected tissues. The pathogenetic mechanisms which may be responsible for the concomitant appearance of these two rather infrequent entities in the same anatomic sites are discussed.

Anti-CD20-based therapy of B cell lymphoma: state of the art

Over the last 5 years, studies applying the chimeric anti-CD20 MAb have renewed enthusiasm and triggered world-wide application of anti-CD20 MAb-based therapies in B cell non-Hodgkin's lymphoma (NHL). Native chimeric anti-CD20 and isotope-labeled murine anti-CD20 MAbs are currently employed with encouraging results as monotherapy or in combination with conventional chemotherapy and in consolidation of remission after treatments with curative intent (ie after/ in combination with high-dose chemotherapy and hematopoietic stem cell rescue). On the available experience, anti-CD20 MAb-based therapeutic strategies will be increasingly integrated in the treatment of B cell NHL and related malignancies.

Evidence for T-large granular lymphocyte-mediated neutropenia in Rituximab-treated lymphoma patients: report of two cases

We report two cases with B cell malignancies (case #1: refractory mantle cell lymphoma; case #2: lymphocyte predominant Hodgkin's disease (LPHD)) who developed neutropenia post-Rituximab therapy in a setting of significant infiltration of the peripheral blood (PB) and bone marrow (BM) by T cells with an immunophenotype of large granular lymphocytes. Possible pathogenetic mechanisms are discussed.

Somatic hypermutation targeting to intrinsic hotspots of immunoglobulin genes in follicular lymphoma and multiple myeloma

In this study, we analyzed the targeting of the somatic hypermutation (SHM) mechanism at specific hotspot sequence motifs in the V(H) and Vkappa genes of 10 follicular lymphoma (FL) cases and the Vkappa and Vlambda genes of 11 kappa- and six lamda-light chain expressing multiple myeloma (MM) cases. These sequences were analyzed for targeting of specific motifs, ie certain highly mutable trinucleotides (3-NTPs), the tetranucleotide (4-NTP) RGYW and its complementary, WRCY (where R = purine, Y = pyrimidine and W = A or T). Comparisons were carried out between mutation frequencies in RGYW vs WRCY and the incidence of mutations in complementarity determining region (CDR)-1 vs CDR2 vs CDR3. Statistically significant differences were obtained when comparing: (1) the ratio of mutations in 4-NTPs (RGYW, WRCY, RGYW+WRCY)/mutations in the whole V sequence in MM-Vkappa vs MM-Vlamda; (2) the total number of mutated 4-NTPs in MM-Vkappa vs FL-Vkappa; (3) the number of mutated RGYW 4-NTPs in MM-Vkappa vs FL-Vkappa and FL-V(H) vs FL-Vkappa; (4) the number of mutated WRCY 4-NTPs in MM-Vkappa vs FL-Vkappa (P= 0.006) and FL-V(H) vs FL-Vkappa; (5) the targeting of RGYW vs WRCY in the CDRs of FL-V(H) genes. Similar results (regarding statistical significance) were obtained when undertaking intergroup comparisons for 3-NTPs. These findings conform well with relevant data derived from normal peripheral B cells. The differences observed in favor of 4-NTP (RGYW and WRCY) targeting in FL-V(H) vs FL-Vkappa and MM-Vkappa vs FL-Vkappa may implicate differences in the evolution of SHM coupled with selection in different stages of B cell ontogeny. Several explanations can be offered for the fact that hotspot sequences were not always targeted by SHM in FL and MM: (1) other unrecognized motifs may be targets of SHM; (2) 'inappropriately' introduced mutations were fixed and propagated by the neoplastic process; (3) certain FL and MM cases might have lost their ability to correct mutations introduced in classic hotspots due to deficient mismatch-repair (MMR) mechanisms; conversely, in other cases with intact MMR function, the hotspot to non-hotspot targeting of somatic hypermutation is balanced.

Simultaneous appearance of mycosis fungoides and chronic lymphocytic leukemia in the same patient

A patient is presented having simultaneously chronic lymphocytic leukemia with a monoclonal B-lymphocyte population and mycosis fungoides with atypical T-cell population in the skin lesion and in the enlarged lymphoid nodes confirmed by detailed phenotyping.

Gingival overgrowth as the initial paraneoplastic manifestation of Hodgkin's lymphoma in a child. A case report

BACKGROUND

The purpose of this paper is to present the first case of gingival overgrowth, premature root resorption, and alveolar bone loss, which preceded the diagnosis of a stage IVB Hodgkin's lymphoma (HL) in a 9-year-old boy.

METHODS

The child presented complaining of gingival pain which first appeared 3 months prior. Clinical examination revealed inflamed, hyperplastic gingivae, while x-ray showed premature root resorption and alveolar bone loss. Medical work-up was significant for cervical lymphadenopathy. Gingival biopsy, followed by lymph node resection, was performed twice.

RESULTS

Histological examination of both gingival biopsies disclosed a mixed inflammatory infiltrate, while classical Hodgkin's lymphoma of the nodular sclerosis type was diagnosed from the second lymph node biopsy. Chemotherapy was instituted with mustard-vincristine-procarbazine-prednizone and adriamycine-bleomycine-vinblastine-dacarbazine. Remission of the lymphoma was observed with concomitant regression of the gingival overgrowth.

CONCLUSIONS

The inflammatory gingival overgrowth, premature root resorption of deciduous teeth, and alveolar bone loss in this case, in conjunction with the regression of gingival overgrowth which followed the completion of chemotherapy, are strongly indicative of a paraneoplastic manifestation of HL. The postulated mechanism for the development of the manifestation is the constitutive activation of the transcription factor NF-kB. The gingival inflammatory reaction was probably further aggravated by the bacterial-stimulated cytokine secretion released by monocytes.

Molecular insights into the immunopathogenesis of follicular lymphoma

Follicular lymphoma is caused by the transformation of a germinal-center-derived B cell with a t(14;18) chromosomal translocation. The distribution of somatic mutations within immunoglobulin genes indicates that follicular-lymphoma cells can interact with antigen. In addition, nonimmunoglobulin genes such as BCL6 seem to undergo somatic hypermutation. Here, Kostas Stamatopoulos and colleagues relate the molecular data about immunoglobulin genes and the protooncogenes BCL2 and BCL6 to the pathogenesis and evolution of follicular lymphoma.

Selection of immunoglobulin diversity gene reading frames in B cell lymphoproliferative disorders

Assembly of immunoglobulin (Ig) heavy (H) variable (V), diversity (D) and joining (J) gene segments constitutes an important determinant of commitment to the B cell lineage. The randomly selected D gene segment of a given VDJ complex can potentially be found in all three possible reading frames (RFs). In the present study, we examined the distribution of D gene RF in 'immature' and 'mature' B cell lymphoproliferative disorders (BCLD). We analyzed the clonotypic VDJ junctional sequences of our previously reported cases of follicular lymphoma (FL), as well as bcl-2/IgH junctions with recognized D elements. A marked under-representation of RF1 was observed, with almost equal usage of RF2 and RF3. A literature search for VDJ published sequences in various BCLD identified a similar pattern of D gene RF usage in multiple myeloma (MM), with marked predilection for RFs 2 and 3. In B cell chronic lymphocytic leukemia (B-CLL), the pattern of D-RF was 25% for RF1, 46% for RF2 and 29% for RF3, while in B cell precursor acute lymphoblastic leukemia (precursor-B-ALL) all three RFs were used with similar frequencies. The marked under-representation of RF1 in FL and MM clonogenic rearranged D genes suggests selection on the basis of antigenic properties, possibly due to constraints in forming a flexible loop within CDR3. In contrast, the more even distribution of D-RF usage in B-CLL and precursor-B-ALL suggests that, for these disorders, transformation of a immature type B cell repertoire has occurred.

Molecular analysis of bcl-1/IgH junctional sequences in mantle cell lymphoma: potential mechanism of the t(11;14) chromosomal translocation

Mantle cell lymphoma (MCL) is characterized by the t(11;14) translocation that juxtaposes the bcl-1 locus to immunoglobulin (Ig) gene sequences and leads to deregulation of cyclin D1 gene. t(11;14) is thought to result from an error of the recombinase during D-JH Ig gene assembly; however, data on the underlying mechanism and candidate recombination-targeting motifs in the major translocation cluster (MTC) of the bcl-1 gene are lacking. bcl-1/IgH junctional sequences from seven MCL patients were amplified by PCR using primers targeting MTC and JH sequences on chromosomes 11q13 and 14q32, respectively. PCR products were directly sequenced and junctional sequences were searched for homology to known germline D genes. bcl-t MTC breakpoints were searched for the presence of possible recombination target motifs; heptamers, nonamers, binding sequence of the bp45 nuclease, x-like sequences and D gene segments. bcl-1/JH junctions were found to bear homology to D gene segments (DLR3, DM and DIR5) in 3/7 MCL samples. A computer-based search in previously published and/or submitted to GenBank bcl-1/JH junctional sequences identified homology to D genes in 1/4 MCL tumour samples and 1/4 MCl cell lines; DXP4 or D23/7 and DHQ52 or D22/21 or DXP5, respectively. The MTC locus contained motifs with homology to bp45 nuclease binding sequence, x-like sequences, heptamers/nonamers, D-like DIR genes and non-homologous recombination short (6 bp) DNA sequences. The above data indicate that the t(11;14) translocation in MCL may also occur at a more mature stage of B-cell ontogeny than previously thought, i.e. during VH-to-DJH rearrangement. Various known recombination motifs within MTC may contribute to an illegitimate recombination event between bcl-1 and DJH.

Extensive apoptosis of bone marrow cells as evaluated by the in situ end-labelling (ISEL) technique may be the basis for ineffective haematopoiesis in patients with myelodysplastic syndromes

Apoptosis is a gene-directed cellular self-destruction which begins with internucleosomal cleavage of DNA and ends eventually with fragmentation of the nucleus. We have shown that the technique of ISEL of fragmented DNA appears to be an accurate and reliable measurement of the early stages of apoptosis. The present study was undertaken in order to define the incidence of programmed cell death in bone marrow (BM) haematopoietic and stromal cells of myelodysplastic syndromes (MDS). The ISEL technique was employed in 21 BM biopsies of MDS patients. The analysis showed that in 11/21 patients, >70% cells (high score) were undergoing programmed cell death while 5 patients showed up to 1/3 of the biopsy containing apoptotic cells and 2 patients had only few occasional ISEL positive cells. Stromal cells including fat cells, endothelial cells and fibroblasts were frequently in apoptosis in large clusters. Our results indicate that extensive apoptosis of haematopoietic cells documented in BM biopsies of MDS patients may be the explanation for the ineffective haematopoiesis which is the hallmark of these disorders.

Oral hairy leukoplakia in a patient with acute lymphocytic leukemia

The first case of oral hairy leukoplakia (OHL) in an HIV-negative 56-year-old patient with acute lymphocytic leukemia (ALL) is reported. A white plaque was observed while the patient was in complete remission which followed the chemotherapeutic scheme. The clinical and histopathologic findings were typical for OHL and the polymerase chain reaction method was positive for Epstein-Barr virus DNA. Underdiagnosis and underreporting of OHL in patients with a malignant haematological disease and the apparent different environmental factors to which these non-AIDS patients have been exposed, probably constitute some of the reasons for the very few OHL cases reported in these patients.

Graft-versus-myeloma after donor leukocyte infusion: maintenance of marrow remission but extramedullary relapse with plasmacytomas

Adoptive immunotherapy with donor leukocytes has emerged as a promising strategy for the treatment of myeloma recurrence after allogeneic transplantation. 2.9 x 10(8)/kg donor mononuclear cells containing 1.4% CD34+ and 37% CD3+ cells were administered to a 48-year-old patient with non-secretory plasmablastic myeloma relapsing 9 months after a blood stem cell transplant from his HLA-identical sibling. In view of the extensive marrow infiltration and the aggressive behaviour of the disease, the donor cells were preceded by a course of EDAP chemotherapy. There was rapid clinical improvement, and CR was achieved on day 30 post infusion. However, three subcutaneous plasmacytomas showing anaplastic features developed within a few days. These failed to respond to interferon-alpha and continued to grow for 5 weeks in the absence of marrow plasmacytosis or other evidence of systemic disease. Grade 3 acute liver GVHD developed on day 79 which was controlled with immunosuppression. Overt systemic relapse occurred on day 90 as the GVHD came under control. The course of our case suggests highly proliferative malignant cells may escape the graft-versus-tumour effect of immunocompetent allogeneic cells in extramedullary sites subsequently resulting in overt systemic relapse if left untreated. New approaches are needed to deal with the problem of extramedullary disease recurrence.

Somatic hypermutation of immunoglobulin variable region genes: focus on follicular lymphoma and multiple myeloma

Analysis of the rearranged immunoglobulin variable region gene hypermutation has provided important information concerning the clonal history and ontogenetic origin of various B-cell lymphoproliferative disorders. Under the selective pressure of antigen, mutational events in immunoglobulin genes will fine tune survival of B-cell clones bearing immunoglobulin with high affinity for antigen. Our studies aimed at analyzing neoplastic disorders originating from germinal and post-germinal center B-cells: follicular lymphoma and multiple myeloma, respectively. Despite the already acknowledged evidence for a selectable distribution of mutations within the clonal immunoglobulin variable heavy chain genes, very little is known about the contribution of light chains in the process of antigen selection. In follicular lymphoma, a more limited pattern of somatic mutation with less evidence of antigen selection was observed in variable kappa light chain genes (40%) than in their partner heavy chain genes (80%). In myeloma, hypermutation of variable light chain genes, with a distribution suggestive of antigen selection, was frequently observed. Based on these data and recent reports it appears that the light chain expressed by the clonogenic myeloma B-cells plays a pivotal role in the antigen selection process. Additionally, abortive kappa light chain variable region genes in lambda-expressing myelomas carried a significant number of somatic mutations indicating that the cell of origin is open to the hypermutation machinery at that particular developmental stage irrespective of antigen selection.

t(14;18) chromosomal translocation in follicular lymphoma: an event occurring with almost equal frequency both at the D to J(H) and at later stages in the rearrangement process of the immunoglobulin heavy chain gene locus

bcl-2/IgH fusion is considered a genetic error which occurs at the diversity (D) to joining (J(H)) stage of the gene rearrangement process in the immunoglobulin heavy chain (IgH) gene locus. Translocations of the bcl-2 protooncogene to the IgH locus at ontogenetically later IgH gene rearrangements are thought to represent exceptions. In the present study we analysed the junctional nucleotide sequence of 18 bcl-2/IgH fusion genes identifiable by polymerase chain reaction performed on DNA extracted from diagnostic lymph node tissue of 14 follicular lymphoma patients. In all clones studied, segments of variable length were found interposed between bcl-2 and J(H) gene sequences. Nucleotide sequence data analysis and comparisons performed with the corresponding germline sequences using the GenBank/EMBL database revealed the presence of D segments in most of the bcl-2/IgH fusion genes under study (13/18). By the same kind of computer-aided analysis, previously unrecognized D segments were identified in many published junctional sequences. These results suggest that bcl-2/IgH fusion events are very prevalent in rather more differentiated stages in B-cell ontogeny than previously recognized.

Follicular lymphoma immunoglobulin kappa light chains are affected by the antigen selection process, but to a lesser degree than their partner heavy chains

Follicular lymphoma cells carry surface immunoglobulin whose heavy chain variable (VH) regions exhibit considerable divergence from the aminoacid sequence predicted by the germline nucleotide sequence as a result of the somatic hypermutation process. The present study examined the extent of somatic hypermutation in follicular lymphoma kappa light chain variable region (V kappa) genes about which the available data is limited. DNA extracted from fresh frozen lymph node tissue of 14 patients with follicular lymphoma at diagnosis was subjected to polymerase chain reaction (PCR) amplification aimed at detecting clonal VH and VL (L: light chain) gene rearrangements. Clonal V kappa gene rearrangements were detected in 10/14 cases. Amplified VH and V kappa genes of these 10 cases were directly sequenced by the dideoxy-chain termination method. In all cases, rearranged VH genes demonstrated numerous mutations clustering in the complementarity determining regions (CDRs), in keeping with previous reports. The degree of divergence of the rearranged V kappa genes from the closest homologous germline V kappa genes varied significantly. Furthermore, two patterns of mutations were observed: (i) in six cases (60%), mutations were most often of the replacement (R) type (changing the aminoacid sequence of the encoded polypeptide) in the CDRs and of the silent (S) type (leaving the aminoacid sequence of the encoded polypeptide unchanged) in the framework regions (FWRs) resulting in R:S ratios significantly greater than would have occurred by chance: (ii) in four cases (40%), very few or no mutations were observed and the distribution of mutations as well as the R:S mutation ratios did not differ significantly from what would have occurred by chance alone. These findings imply that, compared to their partner heavy chains, the kappa light chains of follicular lymphoma neoplastic B-cells' surface immunoglobulin (sIg): (i) are less affected by somatic hypermutation: (ii) play a less significant role in the antigen selection process.

Analysis of the kappa light chain variable region in multiple myeloma

The study of immunoglobulin heavy chain gene rearrangements in multiple myeloma has revealed extensive divergence from the germline sequences, but no intraclonal diversity with disease evolution. Our study investigated the state of the rearranged kappa light chain variable region (V kappa) gene segments as well as abortive V kappa family gene usage in cases of multiple myeloma expressing lambda light chain. We studied 11 cases of kappa and five cases of lambda light chain-expressing multiple myeloma. Total cellular RNA was extracted from the bone marrow of patients with overt disease and subjected to reverse transcription-polymerase chain reaction (RT-PCR) analysis to amplify clonally rearranged variable region sequences. Direct nucleotide sequencing by the dideoxy-chain termination method was performed on the RT-PCR products. We did not observe preferential usage of certain V kappa gene families. Mutation frequencies of the V kappa segments varied in number. In the majority of cases, extensive somatic mutations occurred within the complementarity determining regions (CDRs) of V kappa, whereas only a limited degree of divergence from the germline was observed in others. In all cases studied. replacement mutations tended to cluster in the CDRs, a finding compatible with an antigen-driven somatic hypermutation process. In 3/5 cases of lambda light-chain expressing multiple myeloma, abortively rearranged V kappa gene segments were amplified from genomic DNA; in two cases a non-templated nucleotide insertion rendering the V kappa sequences out-of-frame was observed, and in the third a stop codon was identified in the open reading frame of the V kappa sequence. Somatic mutations were observed in all cases of abortive V kappa genes studied; however, their distribution does not suggest selection by antigen. We conclude that somatic mutations observed in the V kappa regions of myeloma cells are of variable extent and suggest operation of the antigen selection process. Lack of or minimal somatic hypermutation in a few cases may be in some way implicated in the biological heterogeneity of the disease.

Hodgkin's disease in a patient with common variable immunodeficiency

A 61 year old man with long standing common variable immunodeficiency presented with pyrexia, anaemia and leucopenia. A diagnoses of Hodgkin's disease of the bone marrow was made. The typical histopathological and immunophenotypic appearances were clearly distinct from those of T cell lymphoma with Reed-Sternberg-like cells which, in contrast to Hodgkin's disease, is a known complication of common variable immunodeficiency. Complete clinical and histological remission was achieved with combination chemotherapy. The latter was complicated by severe myelosuppression, unusually severe erosive mucositis and viral retinitis.

Detection of gene rearrangements in reactive lymphoid processes

We report the immunohistologic and the genotypic analysis of lymph node biopsies from 23 cases of reactive processes, and two cases of atypical lymphoproliferations (AL). Clonal gene rearrangements were detected in 5 cases of proven reactive processes as well as in both AL, in which no signs of malignancy were detected during the phenotypic analysis. No patient, apart from the two AL cases, showed any progression to malignancy during a follow-up period of 28-43 months after the initial biopsy.