Shivakumar Subramaniyam

Lymphoblastic transformation of follicular lymphoma: a clinicopathologic and molecular analysis of 7 patients

Approximately 30% of patients with follicular lymphoma (FL) transform to a more aggressive malignancy, most commonly diffuse large B cell lymphoma. Rarely, FL transformation results in clinical findings, histology, and immunophenotype reminiscent of B-lymphoblastic leukemia/lymphoma. We report the largest series to date with detailed analysis of 7 such patients. Lymphoblastic transformation occurred on average 2 years after initial diagnosis of FL. Five patients had prior intensive chemotherapy. Two patients developed mature high-grade lymphoma, followed by the lymphoblastic transformation. FL had BCL2 gene rearrangement in 4 of 5 cases. High-grade transformation was accompanied by MYC gene rearrangement (5 of 5). Transformation was characterized by expression of TdT, loss of Bcl6, variable loss of immunoglobulin light chain, and persistence of Pax-5, Bcl2, and CD10. Whole-exome sequencing in 1 case revealed presence of several actionable mutations (CD79B, CCND3, CDK12). FL, aggressive mature B cell lymphoma, and lymphoblastic transformation were clonally related in 6 evaluable cases. After transformation, survival ranged from 1 to 14 months. Four patients died of disease, 2 were in remission after stem cell transplant, and 1 was alive with disease.

Bone marrow morphology predicts additional chromosomal abnormalities in patients with myelodysplastic syndrome with del(5q).

The current World Health Organization classification considers myelodysplastic syndrome with isolated del(5q) a distinct entity owing to its characteristic clinical and pathologic features. Recently, several studies have examined survival, leukemic transformation, and various prognostic factors in these patients. However, there is a lack of detailed comparative pathologic analysis of myelodysplastic syndrome cases in which del(5q) is present in association with additional cytogenetic abnormalities. We studied 26 cases of myelodysplastic syndrome at initial diagnosis with 5q- alone, 5q- plus 1 additional abnormality, and 5q- as part of a complex karyotype. Four of 17 patients had evidence of JAK2 V617F mutation. In contrast to cases of myelodysplastic syndrome with isolated 5q-, patients with additional abnormalities had normal mean corpuscular volume and decreased platelet counts (P < .001). Based on bone marrow examination, they were significantly more likely to have increased cellularity, trilineage dysplasia, lower proportion of small hypolobated megakaryocytes, higher number of blasts, and fibrosis. The presence of these morphologic features can be used to distinguish these more aggressive cases from those with myelodysplastic syndrome with isolated 5q- and a more benign clinical course.

Cutaneous double-hit B-cell lymphoma: an aggressive form of B-cell lymphoma with a propensity for cutaneous dissemination.

Abstract:Diffuse large cell B-cell lymphoma of the skin is most commonly represented by diffuse large cell variants of primary cutaneous follicle center cell lymphoma and the leg-type lymphoma. In a minority of cases, the infiltrates are an expression of stage 4 disease of established extracutaneous B-cell lymphoma. We describe 3 patients with an aggressive form of B-cell lymphoma secondarily involving the skin. Two of the patients were in the ninth decade of life, whereas 1 patient was 34 years of age. In the elderly patients, there was an antecedent and/or concurrent history of follicular lymphoma, whereas in the younger patient, the tumor was a de novo presentation of this aggressive form of lymphoma. The elderly patients succumbed to their disease within less than a year from the time of diagnosis, whereas 1 patient is alive but with persistent and progressive disease despite chemotherapeutic intervention. The infiltrates in all 3 cases were diffuse and composed of large malignant hematopoietic cells that exhibited a round nucleus with a finely dispersed chromatin. Phenotypically, the tumor cells were Bcl-2 and CD10 positive, whereas Bcl-6 and Mum-1 showed variable positivity. One case showed combined Mum-1 positivity along with an acute lymphoblastic lymphoma phenotype, including the absence of CD20 expression. In each case, there was a c-MYC and BCL2/IGH rearrangement diagnostic of double-hit lymphoma. In one case, there was an additional BCL6 rearrangement, defining what is in essence triple-hit lymphoma. In conclusion, double-hit lymphoma is an aggressive form of B-cell neoplasia resistant to standard chemotherapy regimens, which in many but not all cases represents tumor progression in the setting of a lower grade B-cell malignancy.

IgG4 plasma cell myeloma: new insights into the pathogenesis of IgG4-related disease

IgG4-related disease is a newly described systemic fibroinflammatory process, characterized by increase in IgG4-positive plasma cells. Its pathogenesis, including the role of IgG4, remains poorly understood. Plasma cell myeloma is typically associated with a large monoclonal serum spike, which is frequently of IgG isotype. We sought to identify and characterize a subset of IgG4-secreting myeloma, as it may provide a biological model of disease with high serum levels of IgG4. Six out of 158 bone marrow biopsies (4%) from patients with IgG myeloma expressed IgG4. Four patients were men and two were women, with a mean age of 64 (range 53–87) years. Imaging showed fullness of pancreatic head (1), small non-metabolic lymphadenopathy (1), and bone lytic lesions (6). Two patients developed necrotizing fasciitis. All had elevated serum M-protein (mean 2.4, range 0.5–4.2 g/dl), and none had definite signs or symptoms of IgG4-related disease. Four myelomas had plasmablastic morphology. Four had kappa and two had lambda light chain expression. Three cases expressed CD56. Two patients had a complex karyotype. In conclusion, the frequency of IgG4 myeloma correlates with the normal distribution of IgG4 isoform. The patients with IgG4 myeloma appear to have a high rate of plasmablastic morphology and could be predisposed to necrotizing fasciitis. Despite high serum levels of IgG4, none had evidence of IgG4-related disease. These findings suggest that the increased number of IgG4-positive plasma cells is not the primary etiologic agent in IgG4-related disease. Elevated serum levels of IgG4 is not sufficient to produce the typical disease presentation and should not be considered diagnostic of IgG4-related disease.

Double and multiple chromosomal aneuploidies in spontaneous abortions: A single institutional experience

OBJECTIVE: To characterize double and multiple aneuploidies in spontaneous abortions (SAB). MATERIALS AND METHODS: Retrospective analysis of cytogenetics data obtained by culturing/harvesting products of the conception material at our center from 2006 to 2009 was performed. The abnormal cytogenetic results, maternal age, gestational age, and previous pregnancy history were recorded and compared. RESULTS: Double and multiple aneuploidies are rare, however, a high percentage of double (4.6%) and multiple (0.4%) chromosomal aneuploidies were observed in our study of 1502 cases of SAB. Of 1502 cases of SAB evaluated, 70 cases (4.6%) showed double aneuploidy, whereas 6 cases (0.4%) had multiple aneuploidies. The chromosomes most frequently involved in double aneuploidy in the decreasing order were 21, 16, ± X, 22, 18, 13, and 15. The most frequent chromosome combinations observed were: Loss of X/21 (8.5%), 21/22 (4.4%), 16/21 (4.4%), and 7/16 (4.4%). The chromosome combinations in multiple aneuploidy included trisomy of chromosomes X/5/8, 8/20/22, 16/20/22, 14/21/22, and loss of X with 21/21 and 7/21. These abnormalities were significantly observed in women between the age group 40-44 years (59.2%). A high success rate (94%) of obtaining metaphase cells was observed in this study mainly due to the use of direct and long-term cultures. CONCLUSIONS: We observed a high percentage of double (4.6%) and multiple (0.4%) aneuploidies, frequently involving the acrocentic chromosomes 13, 15, 21, and 22 and nonacrocentric chromosomes X, 16, and 18.

Composite Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma and Follicular Lymphoma Are Biclonal Lymphomas A Report of Two Cases

Composite lymphomas (CLs) consisting of 2 indolent B-cell lymphomas are rare. We present 2 CL cases composed of chronic lymphocytic leukemia (CLL) and follicular lymphoma (FL), each with unique clinicopathologic features. In the first case, the FL was negative for IGH-BCL2 and harbored a novel IGH-associated translocation; in the second case, the CL manifested in the skin. The individual components in both CLs were derived from different B-cell clones. This is the first complete characterization, including molecular analysis, of CLs composed of leukemic CLL and FL and the first report of a cutaneous CL derived from 2 low-grade B cell lymphomas. Our results provide additional supporting evidence that CLs of indolent B-cell lymphomas are biclonal and suggest that they are pathogenetically different from CLs composed of a low-grade B-cell lymphoma and an aggressive B-cell lymphoma or Hodgkin lymphoma, which are usually clonally related.

BCR-PDGFRA fusion in a T lymphoblastic leukemia/lymphoma

The BCR-PDGFRA fusion is a very rare event. To date, only eight cases of hematolymphoid neoplasms with the BCR-PDGFRA fusion gene have been reported. All cases except one had eosinophilia. We present the first case of T acute lymphoblastic leukemia with a t(4;22)(q12;q11.2) involving the BCR and PDGFRA genes, without associated eosinophilia. Radiology showed splenomegaly and extensive lymph node involvement. The patient rapidly achieved complete remission with treatment protocol for Philadelphia chromosome-negative acute lymphoblastic leukemia.

Primary Cutaneous Follicle Center Lymphoma Associated With an Extracutaneous Dissemination: A Cytogenetic Finding of Potential Prognostic Value

OBJECTIVES Cytogenetic studies on cutaneous lymphomas are rare, and very little is known about their prognostic value. We present a rare case of primary cutaneous follicle center lymphoma (PCFCL) with a complex translocation presenting with cutaneous and extracutaneous dissemination in the lymph node. METHODS Morphologic, immunohistochemical, conventional cytogenetic, and fluorescence in situ hybridization (FISH) studies were performed on this patient. RESULTS A combination of cytogenetic and FISH analysis identified a complex novel four-way t(2;14;9;3) (p11.2;q32;p13;q27) translocation involving rearrangements of BCL6, immunoglobulin light and heavy chain genes, and an unknown gene on 9p. CONCLUSIONS Our report elaborates the morphologic and immunohistochemical features in combination with cytogenetic and molecular cytogenetic analysis of PCFCL, which provide additional insight into the clinical and biologic behavior of this lesion.

A translocation t(2;14)(p11.2;q32) involving rearrangements of immunoglobulin heavy chain and kappa light chain genes in B-cell lymphoma.

Chromosomal translocations associated with immunoglobulin (IG) loci are characteristic of mature and immature B-cell neoplasms [1]. Immunoglobulin heavy chain (IGH) gene rearrangement is the most common, but variant translocations involving IG light chains, IG kappa (IGK) and IG lambda (IGL), have also been described, typically in Burkitt and mantle cell lymphomas [1–3]. The major molecular consequences due to an IG translocation involve deregulated expression of the partner gene resulting in lymphomagenesis [2]. A literature search revealed a total of 43 different genes that could partner with IGH. The most common translocation partners are CCND1, BCL2, BCL3, BCL6, MYC and PAX5 [1]. The t(2;14) translocation involving rearrangements of IGH with IGK gene is extremely rare [3]. There are only three cases with t(2;14)(p11;q32) reported in the Mitelman database. They were all patients with chronic lymphocytic leukemia (CLL) [4–6] (Table I). Here, we report two cases with B-cell lymphoma: follicular lymphoma (FL) and diffuse large B-cell lymphoma (DLBCL) with a t(2;14) translocation, suggesting a possible involvement of IGK and IGH gene rearrangements by fluorescence in situ hybridization (FISH) analysis. The first patient was a 60-year-old man who presented in 2006 with a history of fever, night sweats and a right supraclavicular lymphadenopathy to an outside institution. His peripheral blood analysis showed a total white blood cell (WBC) count (5.9  103/mm3), platelets (265  103/mm3), hemoglobin (15.6 g/dL), mean corpuscular volume (MCV) 85 fL, mean corpuscular hemoglobin (MCH) 30.5 pg and mean corpuscular hemoglobin concentration (MCHC) 36.1%, and poikilocytosis. Histopathological examination of an excisional biopsy of the lymph node established a diagnosis of FL grade 1–2. The neoplastic lymphoid cells were positive for CD20, CD10, BCL6 and BCL2 and negative for MUM1. Flow cytometric analysis showed B-cells positive for CD10 with monotypic expression of kappa IG light chains. The patient was treated with six cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) chemotherapy and achieved remission in April 2011. One year later a follow-up positron emission topography (PET) and computed tomography (CT) scans showed disease recurrence. He was referred to our institution for further follow-up and management. Immunohistopathological studies of the lymph node biopsy showed relapsed lowgrade FL. Cytogenetic analysis of the lymph node identified the following karyotype: 46,XY,t(2;14)(p11.2;q32),add(12) (q22),t(14;18)(q32;q21.3),ins(17;?)(q21;?)[16]/46,XY[4] [Figure 1(a)]. Interphase FISH analysis was performed on methanol:acetic acid (3:1 ratio) fixed cell pellets using the following probes: IGK (Oxford Gene Technology, Tarry Town, NY) and IGH breakapart, and IGH–BCL2 dual fusion translocation probes (Abbott Molecular Inc., Des Plaines, IL). Two hundred interphase nuclei were scored for each probe and abnormal metaphases were captured whenever available. FISH analysis showed rearrangements of IGH–BCL2 in 90% of cells evaluated [data not shown]. The other IGH allele was also rearranged and was translocated on the der(2) t(2;14) chromosome. A rearrangement of IGK was observed in 92% of the cells. Metaphase FISH showed 3′ IGK on the der(14)t(2;14) and 5′ IGH on the der(2)t(2;14) chromosome, most probably indicating rearrangement of IGH with IGK [Figure 1(b) and 1(c)]. The patient was offered treatment, but he declined therapy. In January 2014 a CT scan of the abdomen/pelvis regions showed worsening lymphadenopathy. Currently the patient is alive with persistent disease, and is being treated symptomatically, 8 years after the initial presentation. The second patient is an 80-year-old woman who presented with a history of generalized weakness and left anterior flank pain of 1 month’s duration. CT and magnetic resonance imaging (MRI) scans identified a left renal mass. Her peripheral blood analysis showed leukocytosis and mild anemia with WBC (15  103/mm3), platelets (211  103/mm3), hemoglobin (11.8 g/dL) and MCV 84.4 fL, and 2% atypical lymphoid cells. Left renal biopsy was performed. Morphologically, there was Leukemia & Lymphoma, October 2015; 56(10): 2992–2994

Micronuclei and nuclear budding in chronic lymphocytic leukaemia.

A 56-year-old man was hospitalized for an episode of angioedema and was found to have lymphocytosis and splenomegaly. Review of a peripheral blood film revealed unusual lymphocyte morphology, including nuclear budding, micronuclei and nucleoplasmic bridges (top). Nuclear budding is a mechanism for elimination of amplified DNA during the S phase of the cell cycle. Micronuclei originate from chromosome fragments that lag behind at anaphase during nuclear division. Nucleoplasmic bridges occur when the centromeres of dicentric chromosomes are pulled to opposite poles of the cell at anaphase. These changes are routinely noted with in vitro testing in mitogen-stimulated cultured human lymphocytes (cytokinesis-block micronucleus assay) and represent markers of genomic instability, including chromosome breakage, chromosome loss and apoptosis. However, these morphological features are exceptionally rare in lymphoid neoplasms. Flow cytometry and cytogenetic analysis were performed and revealed chronic lymphocytic leukaemia (CLL) with a complex karyotype and deletion of TP53 (bottom). CLL cells typically have a very low proliferation rate. Deletion of TP53 is linked to genomic instability, increased proliferation and refractory disease. The patient achieved complete remission with fludarabine and rituximab, but relapsed 5 months later. He is currently being treated with alemtuzumab.