C. S. Chim

CD56 ˛ NK lymphomas: clinicopathological features and prognosis

The surface molecule CD56 marks a category of malignant lymphoma of putative natural killer (NK) cell origin. We conducted a retrospective analysis of 24 cases of CD56+ NK lymphoma/leukaemia to define the clinicopathologic and prognostic features of this specific group of lymphomas. 56 cases of nasal lymphomas and 204 cases with an initial diagnosis of peripheral T‐cell lymphoma were retrospectively analysed. To specifically examine lymphomas of putative NK origin, only those that were negative for surface expression of CD3 but positive for CD56 were analysed. 24 cases were identified. The initial predominant sites of involvement were nasal (nu2003=18), palate (nu2003=u20031), nodal (nu2003=u20031) and multi‐organ (nu2003=4). Clinically, in patients with disease localized to one anatomical site (nu2003=u200320), most had symptoms confined to the nose, with a high percentage in early stage (I: 91%; IV: 9%). The marrow was not involved in any of these cases. However, patients with multi‐organ involvement at presentation (nu2003=u20034) behaved differently. All presented acutely with pancytopenia, hepatosplenomegaly, and marrow infiltration with haemophagocytosis. A leukaemic phase was observed in one case. Anthracycline containing combination chemotherapy resulted in complete remission in 75% of patients with localized disease, but only in 25% with multi‐organ involvement. The median survival of patients with localized disease was 12 months, compared with 2 months in the multi‐organ group (Pu2003=0.06); the disease‐free survival was significantly better in the former (Pu2003<0.01). The overall median survival of all patients was still poor at 11 months.

Epigenetic inactivation of INK4/CDK/RB cell cycle pathway in acute leukemias

Dysregulation of cell cycle is important in oncogenesis. We analyzed the inactivation of the INK4 family CKI/CDK/RB pathway by gene promoter hypermethylation in leukemogenesis. The methylation-specific polymerase chain reaction (MSP) with primers for methylated (M-MSP) and unmethylated (U-MSP) alleles of the p15, p16, p18, and RB genes was used to study five leukemic cell lines, 50 acute myeloid leukemia (AML) and 25 acute lymphoblastic leukemia (ALL) samples. None of the leukemic cell lines showed p18 and RB methylation. p15 was methylated in Raji, while p16 was methylated in U937 and Raji. In NB4 and Jurkat, both alleles of p15 and p16 appeared to be deleted. At diagnosis, p15 methylation occurred in 29 (58%) AML patients, and 10 (40.0%) ALL patients. p16 methylation occurred in two (4%) AML and two (8%) ALL patients. Only one each of AML and ALL patients had concurrent p15 and p16 methylation. None of the patients had methylation of p18 or RB. In AML, p15 methylation was associated with M2 subtype (p=0.018). Patients with and without p15 methylation had similar complete remission (CR) rates and projected 5-year overall survival (OS) or disease-free survival (DFS). Therefore, methylation inactivation of the INK4/CDK/RB pathway in leukemia involved primarily p15 and occasionally p16, but not p18 or RB. In AML, p15 gene methylation was associated with the M2 subtype, but was not prognostic for CR, OS, or DFS.

Aberrant gene promoter methylation in acute promyelocytic leukaemia: profile and prognostic significance.

Summary. Acute promyelocytic leukaemia (APL) has distinct clinicopathological and molecular features. However, the profile of aberrant gene promoter methylation is undefined. In this study, methylation‐specific polymerase chain reaction (MSP) was used to define the methylation status of a panel of nine genes, comprising p15, p16, RARβ, oestrogen receptor (ER), E‐cadherin (E‐CAD), p73, caspase 8 (CASP8), VHL and MGMT, in 29 patients with APL. Aberrant methylation of p15, ER, RARβ, p16 and E‐CAD occurred, respectively, in 23 (79%), 14 (48%), six (21%), six (21%) and two (7%) patients at diagnosis, but p73, VHL, CASP8 and MGMT were not methylated in any patients. There was methylation of one gene in 13 patients (45%), two genes in four patients (14%), three genes in six patients (21%) and four genes in three patients (10%). Concurrent methylation of two or more genes occurred in 13 patients (45%). No association was identified between gene methylation and presenting clinicopathological features. However, p15 methylation was significantly associated with an inferior disease‐free survival (DFS, Pu2003=u20030·008), and remained the only poor prognostic factor in multivariate analysis (Pu2003= 0·019). In APL, p15, p16, ER and RARβ were most frequently methylated. This profile is distinct from other types of myeloid leukaemias. p15 methylation has a poor prognostic impact on DFS.

Epigenetic dysregulation of the Jak/STAT pathway by frequent aberrant methylation of SHP1 but not SOCS1 in acute leukaemias

SOCS1 and SHP1 are negative regulators of the Jak/STAT signalling pathway that is implicated in leukaemogenesis. We studied if aberrant methylation of SOCS1 and SHP1 might be involved in the pathogenesis and prognostication of acute leukaemias by methylation-specific polymerase chain reaction (MSP). At diagnosis, methylation of SHP1 occurred more frequently in acute myeloid leukaemia (AML) (n=26, 52%) than acute lymphoblastic leukaemia (ALL) (n=6, 24%) (p=0.02). Methylation of SOCS1 was absent in both AML and ALL patients. SHP1 methylation was not associated with specific clinicopathologic features and had no prognostic impact on AML patients. Frequent methylation of SHP1, but not SOCS1, may be important in the pathogenesis, but not prognosis, of acute leukaemias.

Reactive Hemophagocytic Syndrome Associated with Penicillium marneffei Infection

Reactive hemophagocytic syndrome (RHS) is characterized by the proliferation of benign but activated histiocytes throughout the reticuloendothelial system, resulting in fever, cytopenia, abnormal liver function, and, often, hepatosplenomegaly and coagulopathy. It was first described by Risdall et al (1) in association with viral infections. Since then many other types of infections, have been reported to be associated with RHS (2). Penicillium marneffei is a dimorphic fungus that is prevalent in Southeast Asia (3), especially in patients with AIDS (4). We report a case of opportunistic Penicillium infection complicated by RHS that responded readily to amphotericin B treatment.

Improved treatment outcome in adult acute lymphoblastic leukemia using the intensive German protocol, a preliminary report

Thirty‐nine consecutive patients with acute lymphoblastic leukemia were treated with an intensive chemotherapy protocol. There were 23 males and 16 females with a median age of 37 years (range: 15–65). Eighteen patients had common ALL, seven had pre‐B ALL, three earlyprecursor B ALL, seven T‐ALL and four had aberrant expression of myeloid antigens (c‐ALL in three and pre‐B ALL in one). The median initial leukocyte count was 11.8×109/l (range: 0.65–295). Cytogenetic result of the marrow was available in 16 of 39 patients (41 per cent) and showed Philadelphia positivity in six, a normal result in six and one each of t(4,11), t(1,19), hyperdiploidy and del 12p. Hepatosplenomegaly was present in about 20 per cent of the patients. l‐Asparaginase‐related hepatic toxicity was the commonest toxicity (48.7 per cent) during phase I of induction. Prolonged pancytopenia and hypoplastic death were common during phase II. With the use of growth factors during the neutropenic period of phase II induction, the rate of hypoplastic death was reduced from 40 per cent to 3 per cent. Common causes of treatment failure included early hypoplastic death (27.8 per cent) and leukemia relapses (50 per cent) while primary refractory leukemia, hepatic failure and perforated peptic ulcer contributed to 11.1, 5.5 and 5.5 per cent of the other deaths. A high complete remission (CR) rate (87·4 per cent) was achieved after phase I induction. The median event‐free survival (EFS) was 8 months and the 3‐year event‐free survival was 43 per cent. This result compared favourably to the other regimens previously employed in our institution. In conclusion, satisfactory survival can be achieved with this intensive regimen. Good supportive care was however, essential to minimize toxicities.

Two cases of therapy-related acute promyelocytic leukemia (t-APL) after mantle cell lymphoma and gestational trophoblastic disease

Abstract. We report two cases of secondary acute promyelocytic leukemia (APL). One patient presented with concurrent APL and missed abortion 1xa0year after etoposide-based chemotherapy for gestational trophoblastic disease. A prolonged complete remission was achieved with standard chemotherapy. An elderly man developed APL 1xa0year after alkylator-based chemotherapy for mantle cell lymphoma (MCL). A complete clinical and molecular remission was obtained with chemotherapy and all-trans retinoic acid, followed by arsenic consolidation. Concomitant molecular relapse of APL and MCL clones was detected at 1xa0year, both of which responded to oral arsenic therapy. High-dose epipodophyllin is a dose risk for secondary APL, but alkylating agents may also be implicated. For patients with a history of active malignancy and heavy previous chemotherapy exposure, the use of nontoxic arsenic therapy appeared to be effective and prudent.

Primary B cell lymphoma of the mediastinum

Primary B cell mediastinal lymphoma has been recognized as a distinct entity recently. This is a retrospective study to define the clinical features and treatment outcome over a 10‐year period. Twenty‐four consecutive patients (male/female: 11/13) with B cell lymphoma primarily involving the mediastinum were studied. The median age was 34 years. Symptoms were mainly referrable to the chest, with superior vena cava syndrome (SVCO) present in one‐third of the patients. Bulky disease was present in over half (58 per cent) and B symptoms were present in 38 per cent of patients. The overall CR rate was 70 per cent and the 5‐year OS rates were 56 per cent and 72 per cent for all and CR patients respectively. Five (71 per cent) primary refractory patients and four (66 per cent) relapsed patients died despite salvage therapy. Six relapses occurred at a median of 6 months from treatment. This study showed that primary large B cell lymphoma of the mediastinum is a clinically distinct entity affecting young patients. A significant proportion attained CR and overall, more than half achieved prolonged remission, and most of the relapses occurred early. However, those who failed to attain CR or relapsed still had a poor outcome. An intensive therapy such as autologous bone marrow transplant has to be considered in this subgroup of patients.

Chronic lymphocytic leukaemia involving the gallbladder.

A 62-year-old woman was diagnosed as Rai stage IV B-cell chronic lymphocytic leukaemia in 1996. She achieved a partial remission with prednisolone and chlorambucil. In 1999, she presented with acute onset of fever and right upper quadrant pain, suggestive of acute cholecystitis. Emergency cholecystectomy was performed; the gallbladder measured 9 3 cm. No gallstone was identified. Histological examination showed transmural infiltration of the gallbladder with a monotonous population of small lymphoid cells with round to oval nuclei (top 40; bottom, 400, haematoxylin and eosin stained). Germinal centres and proliferation centres were not identified (top) Immunohistochemical study showed that these lymphoid cells were positive for CD20 (L26) with aberrant expression of CD5, but were negative for T-cell markers CD3 and CD43 (UCHL1), and cyclin D1. Polymerase chain reaction (PCR) for immunoglobulin heavy chain (IgH) gene rearrangement on DNA extracted from paraffin tissue showed a monoclonal band. The patient remains alive with disease 5 years from diagnosis.

Breast and pelvic masses in a myeloma patient

Dear Editor, A 52-year-old mentally retarded woman initially presented with hypercalcemia (adjusted calcium level 3.11 mmol/L) and anemia (hemoglobin level 8.3g/dL) in April 2006. Upon presentation, she had elevated IgG (7410 mg/dL) with immunoparesis, i.e., decreased IgM (30 mg/dL) and IgA (12 mg/dL) levels. An IgG lambda paraprotein of 42.9 g/L was detected by serum protein electrophoresis. Bone marrow was nearly completely replaced by CD 138 positive plasma cells. Skeletal survey revealed generalized osteopenia with multiple lytic lesions in the ribs. She was thus diagnosed to have international staging system stage 2 multiple myeloma and was treated with combination of mephalan, thalidomide, and prednisolone as well as regular zoledronic acid infusion. Initially, she had a significant reduction in paraprotein level from 42.9 g/L to 23.6 g/L. However, her calcium level remained persistently elevated (>3.0 mmol/L). Her renal function had been normal and she was asymptomatic despite the persistent hypercalcemia. Other potential causes of persistent hypercalcemia were considered. Tumor markers and parathyroid hormone level were checked. Surprisingly, both CA 15.3 and CA 125 levels were found to be grossly elevated at 131 U/ml (normal <23 U/ml) and 82.7 U/ml (normal <35 U/ml), respectively, whereas other tumor markers and parathyroid hormone level were normal. Based on these findings, further investigations were performed to exclude second malignancy, in particular, breast and ovarian cancer. Mammogram showed a clinically occult mass of 5×8× 10 mm in size in her right breast (Fig. 1). Moreover, computed tomography of the pelvis revealed two contrast enhancing soft tissue masses: 5.5×6.5×7 cm on the left side of urinary bladder (Fig. 2 thin arrow) and 2.1×2.9× 2.5 cm infiltrating left obturator muscle (Fig. 2 thick arrow). Unexpectedly, aspiration cytology of the right breast mass showed pleomorphic cells with prominent nucleoli highly suggestive of myeloma involvement (Fig. 3a), whereas the pathology of her left pelvic mass also demonstrated plasma cells with hyperchromatic nuclei and prominent nucleoli (Fig. 3b) which were CD 138positive on immunohistochemical staining (Fig. 3c). Simultaneously, her paraprotein level also resurged to 31.7 g/L. She was thus treated as progressive myeloma disease with bortezomib. However, her disease was refractory to treatment. Her IgG level and paraprotein continued to rise while her calcium remained at about 3.0 mmol/L. Figure 4 shows the change of IgG concentration level with time. Her CA 15.3 level also increased to 169 U/ml. Her condition gradually deteriorated and finally succumbed to sepsis after three courses of bortezomib treatment. Unfortunately, autopsy examination was refused by patient’s relatives. Extra-medullary plasmacytoma occurs in around 15% of patients at the time of diagnosis of multiple myeloma and an additional 15% during the course of the disease [1]. The most common sites of involvement are upper airway and gastrointestinal tract. Breast and pelvic involvement are rare. The prognosis of patients with extra-medullary plasmacytoma varies. Patients with primary solitary plasmacytoma usually carry good prognosis. Local treatment, such as radiotherapy or surgical resection is curative in the majority of cases and less than 30% develop frank myeloma or multiple extra-medullary tumors in 10 years [2]. In contrast, the outcome of patients with plasmacytoma Ann Hematol (2008) 87:1027–1029 DOI 10.1007/s00277-008-0522-8