Joseph A. DiGiuseppe

Intravascular lymphomatosis: a clinicopathologic study of 10 cases and assessment of response to chemotherapy.

PURPOSEnWe report a clinicopathologic study of 10 cases of intravascular lymphomatosis (IVL) seen at a single institution, and assess the response to chemotherapy in these patients, as well as those collected from a literature review.nnnPATIENTS AND METHODSnThe clinical, pathologic, and immunophenotypic features of 10 cases of IVL diagnosed at the Johns Hopkins Hospital since 1977 were studied. Follow-up information was obtained in each case by consultation with the treating physician. In addition, cases of IVL reported previously in which patients were treated with chemotherapy and for which follow-up data were available at the time of publication were reviewed.nnnRESULTSnIn the present series of 10 cases, the most common clinical features were fever of unknown origin (FUO), mental status changes, and rash. Diagnostic specimens were obtained from a variety of sources, including brain, skin, prostate, liver, kidney, and gallbladder. All of the four patients treated with combination chemotherapy are alive and two have achieved long-term survival (48 and 45 months, respectively); the remaining two are alive and in complete remission (CR) after short follow-up duration of 6 months. Among 35 patients reported in the literature who received chemotherapy (including four from this series), 43% attained a CR and were free of disease at the time of publication. None of the three patients in our series who received localized therapy (surgery with or without radiation therapy) is alive (mean survival duration, 9 months). For the three patients diagnosed at postmortem examination, the mean interval between onset of symptoms and death was 3 months, and disease was widespread.nnnCONCLUSIONnThese findings suggest that IVL represents a high-grade non-Hodgkins lymphoma (NHL) with a propensity for systemic dissemination, and that CR and long-term survival may result in patients treated with aggressive combination chemotherapy.

Immunohistochemical evaluation of HER-2/neu expression in pancreatic adenocarcinoma and pancreatic intraepithelial neoplasms☆

Although several morphological and molecular genetic studies have implicated various grades of pancreatic duct hyperplasia as precursor lesions to infiltrating pancreatic adenocarcinoma, the identity of preinvasive pancreatic neoplasms remains controversial. In the present study, the authors examined the expression of the epidermal growth factor receptor homologue, HER-2/neu (c-erbB-2), in pancreatic duct lesions adjacent to infiltrating pancreas cancers in a series of 19 cases of pancreatic duct adenocarcinoma. HER-2/neu expression was examined because it has been identified in a proportion of infiltrating pancreas cancers and because it may provide early neoplasms with a growth advantage over adjacent nonneoplastic epithelium. In normal pancreatic ducts and ductules, HER-2/neu expression was absent in all but one case. By contrast, HER-2/neu was expressed in 82% (P = .008 vs normal ) of ducts with flat mucinous hyperplasia, 86% (P = .03 vs normal) of ducts with papillary mucinous hyperplasia without atypia, 92% (P = .001 vs normal) of ducts with atypical papillary mucinous hyperplasia, and all specimens with carcinoma in situ. HER-2/neu expression was observed in 69% (P = .002 vs normal) of the moderately differentiated infiltrating carcinomas and none of the poorly differentiated infiltrating carcinomas. These data establish HER-2/neu as a potential mediator of growth factor-related signal transduction in pancreatic duct lesions, and provide additional support for the hypothesis that lesions formerly regarded as various grades of hyperplasia instead may represent intraepithelial neoplasms with the potential for subsequent invasion and metastasis.

Blastic natural killer cell leukemia/lymphoma: A clinicopathologic study

The classification of natural killer (NK)-cell and NK-like T-cell malignancies has undergone significant evolution in recent years. Although examples of NK-cell tumors resembling acute leukemia have been described anecdotally as blastic, blastoid, or monomorphic NK-cell leukemia/lymphoma (NKL/L), the clinical and pathologic features of these tumors have not been systematically defined. We report four patients with blastic NKL/L and describe the clinical, pathologic, and immunophenotypic findings in these cases. All patients were elderly (58-82 years) and presented with cutaneous plaques. Two patients also had adenopathy, and three patients had marrow involvement at presentation. Biopsy of cutaneous lesions showed atypical superficial and deep dermal lymphoid infiltrates. Involved lymph nodes were architecturally effaced by an interfollicular infiltrate with blastic cytologic features. In Wright-Giemsa-stained blood or marrow smears, tumor cells had finely distributed nuclear chromatin, many with nucleoli, and variable amounts of cytoplasm. In contrast to many NK and NK-like T-cell disorders, azurophilic cytoplasmic granules were absent or inconspicuous. The tumor cells were immunophenotypically distinctive. They expressed intermediate density CD45, as is characteristic of blasts; in addition, the cells were positive for HLA-DR, CD2, CD4, and the NK-associated antigen CD56. Surface CD3, cytoplasmic CD3, and CD5 were negative in all cases tested, whereas CD7 was expressed in two cases. In formalin-fixed tissue, tumor cells marked with antibodies to CD43, but not with other T- or B-lineage-related antibodies. All three cases studied for Epstein-Barr viral RNA by in situ hybridization were negative. Although treatments varied, all three patients with clinical follow-up died within months of the diagnosis. The clinical course in two patients culminated in an overtly leukemic phase. These findings suggest that blastic NKL/L represents a distinct clinicopathologic entity, characterized by cutaneous, nodal, and marrow involvement by blastic cells with immunophenotypic characteristics of true NK cells. The disease afflicts elderly patients, pursues an aggressive course, and may culminate in overt leukemia.

Increasing incidence of minimal residual cancer in radical prostatectomy specimens

Residual cancer in radical prostatectomy specimens from men with biopsy-proven adenocarcinoma occasionally may be difficult, or even impossible, to identify. Although this finding was recently described as minimal residual cancer or the vanishing cancer phenomenon, there are no data on the incidence of this phenomenon in surgical pathology practice. We evaluated 3,038 consecutive radical prostatectomies performed at the Johns Hopkins Hospital between 1988 and 1995, excluding cases with a history of transurethral resection, prior therapy with a luteinizing hormone-releasing hormone agonist, focal Gleason grade 4 or 5, capsular penetration, or a positive surgical margin. Of this group, 84 cases with minimal or no residual cancer were identified. In 60 of these cases, residual cancer was difficult to find (mean total volume, 0.03 cc; range, 0.01-0.08 cc); in 20 cases, residual cancers were classified as minute (mean total volume, 0.07 cc; range, 0.03-0.13 cc). In four cases, no residual cancer could be identified, including two cases in which the diagnosis of cancer on needle biopsy was confirmed, one case in which review of the diagnostic needle biopsy revealed only high-grade prostatic intraepithelial neoplasia, and one case in which molecular analysis demonstrated mislabeling of the needle biopsy specimen. The annual incidence of minimal residual cancer increased from 0.5% in 1988 to 4% in 1993 and has begun to plateau at 3 to 4% since 1993 (p = 0.0016 for increasing trend). These data confirm the general impression that with more vigilant screening of men for prostate cancer, there has been an associated increase in cancer with little or no residual cancer at radical prostatectomy.

Hepatosplenic and Subcutaneous Panniculitis-Like γ/δ T Cell Lymphomas Are Derived from Different Vδ Subsets of γ/δ T Lymphocytes

Gamma/delta T cell lymphomas (γ/δ TCL) represent rare, often aggressive types of T cell malignancy that are clinically and pathologically diverse. Most γ/δ TCL occur as a hepatosplenic or subcutaneous type. To date, analysis of the T cell receptor δ (TCRδ) gene repertoire of hepatosplenic γ/δ TCL (γ/δ HSTCL) and subcutaneous panniculitis-like γ/δ TCL (γ/δ SPTCL) has been reported only in a limited number of cases. In this study we analyzed 11 γ/δ HSTCL and 4 γ/δ SPTCL by polymerase chain reaction and immunostaining to determine their usage of the Vδ subtypes (Vδ1–6). It is noteworthy that 10 of 11 γ/δ HSTCL expressed the Vδ1 gene. The remaining case also expressed T cell receptor δ (TCRδ) as determined by flow cytometry and TCRδ rearrangement in Southern blot. However, the Vδ gene expressed by this lymphoma could not be determined, which suggests usage of an as yet unidentified Vδ gene. In striking contrast to the γ/δ HSTCL, all 4 γ/δ SPTCL expressed the Vδ2 gene. Our data demonstrate that γ/δ HSTCL are preferentially derived from the Vδ1 subset of γ/δ T lymphocytes, whereas γ/δ SPTCL are preferentially derived from the Vδ2 subset. The pattern of Vδ gene expression in HSTCL and SPTCL corresponds to the respective, predominant γ/δ T cell subsets normally found in the spleen and skin. This finding suggests that γ/δ TCL are derived from normal γ/δ T lymphocytes which reside in the affected tissues. Furthermore, the selective, lymphoma type-specific Vδ gene segment usage may provide a molecular tool to distinguish better among various types of γ/δ TCL lymphoma particularly in the clinically advanced, widely disseminated cases.

Absence of Epstein‐Barr virus EBER‐1 transcripts in an epidemiologically diverse group of breast cancers

Epstein‐Barr virus (EBV), a ubiquitous herpesvirus associated with certain lymphomas and carcinomas, has been identified within the malignant cells of a small proportion of breast tumors. As breast cancer is a very common malignancy in women, a pathogenetic role of EBV for even a subgroup of patients could have important implications for etiology and prevention. Therefore, we attempted to confirm the EBV–breast cancer association by exploring it in a representative case series stratified by characteristics that modify breast cancer risk. We studied a sample of 97 female and 28 male patients identified from a US population‐based cancer registry. Patients were selected randomly within age, sex, ethnicity and tumor estrogen‐receptor status groups. With their archived tumor tissues, we examined EBV presence using in situ hybridization for the EBER‐1 transcript. In the 107 technically adequate specimens, we did not detect this viral transcript in any tumors, including one from a woman who also had an EBER‐positive nasopharyngeal carcinoma. Our uniformly negative findings are extremely unlikely to have occurred by chance and cannot be attributed to selective sampling, as our study group included persons at diverse risk for breast cancer. We conclude that the EBV EBER‐1 transcript is not commonly expressed in breast cancer, based on a broadly representative case series, though we cannot exclude an association of EBV within a particular population subgroup. Int. J. Cancer 75:555–558, 1998.

Phenylbutyrate-induced G1 arrest and apoptosis in myeloid leukemia cells: structure–function analysis

The aromatic fatty acid phenylbutyrate (PB) induces cytostasis, differentiation, and apoptosis in primary myeloid leukemic cells at clinically achievable concentrations. In the present study, we have investigated the structural and cellular basis for PB-induced cytostasis, using the ML-1 human myeloid leukemia cell line as a model system. PB induced a dose-dependent increase in cells in G1 with a corresponding decrease in cells in S-phase of the cell cycle. At comparable doses, PB induced expression of CD11b, indicating myeloid differentiation. At higher doses, the drug induced apoptosis. The antitumor activity was independent of the aromatic ring, as butyric acid (BA) was of equal or greater potency at producing these biological changes. In contrast, shortening of the fatty acid carbon chain length, as demonstrated with phenylacetate (PA), significantly diminished drug potency. Consistent with their effects on cell cycle, PB and BA, but not PA, induced the cyclin-dependent kinase inhibitor, p21WAF1/CIP1, and led to the appearance of hypophosphorylated Rb, suggesting a role for p21WAF1/CIP1 in PB-induced cytostasis. Therefore, it appears that the fatty acid moiety of PB, rather than its aromatic ring, is critical for its activity in myeloid leukemic cells. These data provide a potential mechanistic basis for the increased potency of PB over PA previously demonstrated in primary leukemic samples, and support the further clinical development of PB in the treatment of hematologic malignancies.

LYMPHOID INFILTRATES OF THE SALIVARY GLANDS : PATHOLOGY, BIOLOGY, AND CLINICAL SIGNIFICANCE

Lymphoid infiltrates of the salivary glands are common to a variety of pathologic conditions including autoimmune disorders, malignant lymphomas, and immunoregulatory responses to parenchymal neoplasms. Clearly, the correct identification of these salivary gland lymphoid infiltrates has important implications regarding patient prognosis and management. Immunophenotypic and molecular analyses have demonstrated that many lesions formerly regarded as myoepithelial sialadentis or benign lymphoepithelial lesion in fact represent neoplastic lymphoid proliferations with the potential for extrasalivary dissemination. In the most recent classification scheme of non-Hodgkins lymphomas, these neoplasms fall within the spectrum of low-grade B-cell lymphoma of mucosa-associated lymphoid tissue. In the early stages of HIV infection, patients may develop salivary gland enlargement resulting from cystic lymphoepithelial lesions. These lesions are thought to reflect a localized manifestation of persistent generalized lymphadenopathy. Although HIV-associated salivary gland disease is regarded as a benign condition, malignant lymphoma has been described in association with some of these lesions, and further work is required to define more precisely the risk of salivary gland lymphoma in HIV-infected patients. Tumor-associated lymphoid proliferation refers to a prominent lymphoid reaction accompanying certain epithelial tumors of the salivary glands. Although tumor-associated lymphoid proliferation has not received as much attention as other types of salivary lymphoid infiltrates, it is a common phenomenon that is sometimes mistaken for an intraparotid lymph node harboring metastatic carcinoma.

Molecular Biology and the Diagnosis and Treatment of Adenocarcinoma of the Pancreas

Abstract: The diagnosis of infiltrating adenocarcinoma of the pancreas is associated with an overall 5‐year survival of <5%. However, recent advances in surgical treatment of pancreatic cancer combined with the use of adjuvant chemoradiation therapy, have improved the outlook substantially. Although conventional pathologic features, such as tumor size, and status of surgical margins and lymph nodes have prognostic importance in patients with pancreatic cancer, novel approaches seem to be necessary to enhance our ability to predict outcome and select optimal therapies. In the case of colonic carcinoma, which has served as a paradigm for our understanding of the molecular basis of neoplasia, somatic mutations in critical oncogenes and tumor suppressor genes accompany progression from adenoma to carcinoma. A similar pattern is emerging for pancreatic cancer in that (a) there appears to be progression from intraductal lesions to infiltrating carcinoma, and (b) the K‐ras oncogene and several tumor suppressor genes, including p53, deleted in colon cancer, and multiple tumor suppressor‐1, are common targets of mutation and/or deletion. Cytogenetic and molecular studies of allelic loss suggest that additional oncogenes and tumor suppressor genes involved in the pathogenesis of pancreatic cancer remain to be discovered. These findings enhance our understanding of the etiology of pancreatic adenocarcinoma and serve as the basis for early detection and potentially for improved treatment of this commonly fatal malignancy.

Apoptosis in haematological malignancies

In recent years, there has been a considerable effort to understand the mechanisms by which cells cause their own demise. This process, known as programmed cell death or apoptosis, is an important regulatory mechanism in normal tissue development and homeostasis. Abnormalities in apoptotic pathways contribute to a diverse array of pathological processes including cancer, immune disorders, and neurodegenerative diseases. The haematopoietic system provides many examples of the significance of apoptosis, both as a regulatory mechanism under normal conditions, and as a pathogenetic element in neoplasia. 6̀ Specifically, acquired resistance to apoptosis can both facilitate the development of haematological malignancies and render these tumours resistant to therapy. This review highlights several examples illustrating the significance of apoptosis in haematological malignancies.