Tullio Artusi

Marker Expression in Peripheral T-Cell Lymphoma: A Proposed Clinical-Pathologic Prognostic Score

PURPOSE Although peripheral T-cell lymphoma, unspecified (PTCL/U), is the most common T-cell tumor in Western countries, no study to date has been based on the application of a wide panel of markers to a large series of patients and assessed the impact of phenotype on survival. We evaluated the expression of 19 markers in 148 PTCLs/U and 45 PTCLs of the angioimmunoblastic type (AILD). PATIENTS AND METHODS The analysis was performed on tissue microarrays by immunohistochemistry and in situ hybridization. Clinical data were available in 93 PTCL/U patients, most of whom had been included in a previous study proposing a prognostic index (PIT). RESULTS An aberrant phenotype with frequent loss of CD5 and/or CD7 was typical for PTCLs, irrespective of whether they were U or AILD. Aberrantly expressed proteins rarely included CD20, CD15, and CD30. Positivity for Epstein-Barr virus-associated small RNAs and CD15 expression emerged as adverse prognostic factors. Among PTCLs/U, the proliferation-associated protein Ki-67 turned out to be prognostically relevant and was integrated in a new predictive score, incorporating age (> 60 years), high lactate dehydrogenase, poor performance status, and Ki-67 > or = 80%. This score was associated with the patient outcome (P < .0001) and was found to be more robust than PIT (P = .0043) in the present series. CONCLUSION Our retrospective analysis shows a wide range of protein expression in PTCLs and proposes a new prognostic index. The latter represents one of the first examples of mixed score (including patient- and tumor-specific factors) applied to malignant lymphomas and may be the basis for future prospective therapeutic trials.

Frequent detection of human herpesvirus-6 sequences by polymerase chain reaction in paraffin-embedded lymph nodes from patients with angioimmunoblastic lymphadenopathy and angioimmunoblastic lymphadenopathy-like lymphoma.

In search of a possible involvement of viral agents in angioimmunoblastic lymphadenopathy with dysproteinaemia (AILD) and AILD-like lymphoma (AILD-L), we studied the presence of human herpesvirus-6 (HHV-6) in the lymph node biopsies of 12 cases by polymerase chain reaction (PCR). Given the rarity of this lymphoproliferative disorder, we investigated archival specimens, consisting of formalin-fixed and paraffin-embedded tissues, obtained from patients with a clinical and histologic diagnosis of AILD and AILD-L. HHV-6 sequences were detected in the lymph node biopsies of 7 out of the 12 AILD and AILD-L cases examined. HHV-6 sequences were identified also in the involved liver and spleen tissues of one patient and in the PBMCs of two patients, all carrying viral sequences in the affected lymph nodes. We also used PCR to characterize the HHV-6 genomes, showing that two different viral strains are represented in the pathologic tissues. This study provides evidence of the presence of HHV-6 specific sequences in an unexpectedly high proportion of our series of AILD and AILD-L cases, suggesting a possible involvement of this lymphotropic virus in the pathogenesis of at least some cases of the disease.

Primary high-grade mucosa-associated lymphoid tissue-type lymphoma of the cervix presenting as a common endocervical polyp

Lymphomas of the uterine cervix are uncommon neoplasms and typically appear as diffuse cervical enlargement. We describe a rare case of primary high-grade lymphoma of mucosa-associated lymphoid tissue of the uterine cervix in a 46-year-old white woman. The tumor, incidentally disclosed at gynecological examination, appeared as a single common polyp. Immunohistochemical investigation found the lesion to consist of a monomorphic CD20-positive infiltrate of large blasts and rare intermingling centrocyte-like lymphoid cells. A dense area of monotypic (lambda light-chain restriction) plasma cells was found beneath the endocervical mucosa; only a few scattered lymphoepithelial lesions were present. The neoplastic cells did not stain for CD5, CD10, CD23, CD43, or cyclin D1. A bone marrow biopsy displayed a paratrabecular, centrocyte-like B-cell infiltration, but no lymphadenopathy was detected by instrumental examination (computed tomographic scan, magnetic resonance imaging). The tumor was successfully treated by multiagent chemotherapy followed by total hysterectomy. To our knowledge, this case represents the second reported example of mucosa-associated lymphoid tissue-type lymphoma occurring in the uterine cervix. We highlight the very unusual gross appearance of this case and emphasize the difficulty of interpreting lymphoid infiltrates in the lower genital tract by microscopy.

Sinus Histiocytosis with Massive Lymphadenopathy

To date, the morphological aspects of sinus histiocytosis with massive lymphadenopathy (SHML) have been fully described. The disease is characterized by an enlargement of lymph nodes in which the sinuses are dilated and infiltrated by histiocytes, often phagocytosing lymphocytes. Even if the prognosis is usually benign and not requiring therapy, several fatal cases have been reported. The etiology is still obscure and the biology is not yet completely clear. Recent immunophenotypical studies suggest that histiocytes may belong to the T-zone associated histiocyte lineage. They may be cytologically homogeneous, but can express different antigenic patterns according to their stage of differentiation. Cytogenetic and molecular aspects of the disease have only been sporadically investigated. In order to better understand the pathogenesis of SHML, which seems to be a disorder lying in between the fields of infections, immunological disease and neoplasia, it is considered very useful to systematically employ a variety of immunophenotypical, cytogenetic and molecular techniques to study the disease, particularly in cases which are clinically atypical or with a more aggressive evolution.

Lymphoid blastic crisis at the onset of chronic granulocytic leukemia: report of two cases.

Two patients with a typical hematologic pattern of acute lymphatic leukemia were brought into complete remission by treatment. A few weeks later they developed a typical peripheral and bone marrow pattern of chronic granulocytic leukemia, with Philadelphia chromosome and very low leukocyte alkaline phosphatase. These cases, along with other findings recently reported in the literature, support the possibility of a previously unrecognized relationship between lymphoblastic cell populations and chronic granulocytic leukemia. Cancer 40:865–870, 1977.

Chronic eosinophilic leukaemia with ETV6-NTRK3 fusion transcript in an elderly patient affected with pancreatic carcinoma

To the Editor: An 82-yr-old woman with previous history of breast cancer, surgically treated in 1992, and arterial hypertension underwent distal pancreatectomy and splenectomy in July 2008 for a poorly differentiated adenocarcinoma of the pancreatic tail with regional lymph nodes and liver metastases. She was subsequently started on palliative chemotherapeutic treatment, consisting of gemcitabine 1000 mg ⁄m days 1 and 8 every 3 wk. On February 2009, having completed eight cycles, the chemotherapy was withdrawn because hepatic metastases increased in size and number. Until March 2009, the complete blood count was unrevealing (WBC count 7.2 · 10 ⁄L with a normal differential count, Hb 10.2 g ⁄dL, Plt count 300 · 10 ⁄L). One month later, the patient was admitted because of low-grade fever, bone pain and marked fatigue. The laboratory investigations revealed leukocytosis with marked eosinophilia and thrombocytopenia (WBC count 73 · 10 ⁄L with eosinophils 78%, Hb 11.4 g ⁄dL, Plt count 69 · 10 ⁄L). The diagnostic work-up excluded either allergic reactions or parasitic infestations or autoimmune disorders or T-cell populations with an abnormal phenotype (1, 2), raising the hypothesis of an eosinophilic leukaemoid reaction secondary to the metastatic pancreatic cancer (3). However, the morphological examination of peripheral blood (PB) smear showed eosinophilia accompanied with circulating myeloid immature precursors and blasts (3%) (Fig. 1A), while bone marrow (BM) trephine biopsy documented marked proliferation of eosinophil granulocytopoiesis, with a blast cell count < 20% (Fig. 1B). Moreover, moderate to severe BM fibrosis was documented on Gomori methenamine silver staining (not shown). These morphological pictures were consistent with a myeloproliferative neoplasm with eosinophilia (MNE) (4). Unfortunately, serum tryptase level was not measured. Extensive FISH and molecular studies on both PB and BM samples failed to detect PDGFRA, PDGFRB and FGFR1 rearrangements (4), but the clonality of the myeloid population was confirmed by further cytogenetic and FISH studies. In particular, conventional G-banding showed 46, XX, )7, +8 karyotype (Fig. 2A), while whole chromosome painting and metaphase FISH examinations performed with specific probes showed that ETV6 gene, located on 12p13, was cryptically rearranged with 15q25 (Fig. 2B,C). A submicroscopic t(12;15)(p13;q25) resulting in the fusion gene ETV6-NTRK3 on der(15) was thus documented. Moreover, RNA isolated from the BM sample was subjected to reverse transcriptase–PCR using primers designed to amplify either the 731-bp solid cancer ETV6-NTRK3 variant (5) or the 601-bp acute myeloid leukaemia (AML) ETV6-NTRK3 variant (6). These latter molecular analyses demonstrated the 731and 1265-bp products, respectively, as expected when the solid cancer-associated fusion transcript is detected (Fig. 2D). Both FISH and molecular examinations, performed as described (7) on formalin-fixed paraffinembedded pancreatic carcinoma sections, were negative for ETV6-NTRK3 fusion transcript, whereas amplification of ETV6 gene was documented (not shown).

Massive bone marrow crystal-storing histiocytosis in a patient with IgA-lambda multiple myeloma and extensive extramedullary disease. A case report.

We report a case of multiple myeloma (MM) displaying an unusual course, with metastatic spread in uncommon sites (gastroduodenal and upper respiratory tract, breast, skin and liver) and with a fatal outcome. In our patient this plasma cell neoplasm was associated with a rare condition named crystal-storing histiocytosis (CSH), resulting from the storage in reactive histiocytes of crystalline immunoglobulin inclusions. These crystal-forming paraprotein components are secreted by the neoplastic plasma cells and give rise to the crystalline material of the histiocytes only after their ingestion and degradation by the same histiocytes. In this disorder crystal-storing cells may be present in various tissues (in our case mainly in bone marrow), often with functional alterations of the involved organs. In our opinion the association of this “atypical” MM with CSH is to be considered an uncommon event.

Cytogenetic and molecular studies in primary myelofibrosis

Cytogenetic and molecular data of three patients affected by primary myelofibrosis with myeloid metaplasia (PMMM) evolving to blastic crisis are reported. The cytogenetic findings were uncommon. The first patient (female) showed an idic(X)(q13) as the sole alteration in chronic phase, with an additional r(7) in 67% of the cells of the blast crisis; the other two patients showed, in blast crisis, a partial trisomy of the long arm of chromosome 1, without translocation, as a unique structural abnormality. These findings confirm the presence of nonrandom, although nonspecific, alterations in PMMM that, in our cases, seem to be related to the multistep progression of the neoplastic process. Molecular investigations have been applied to study the genomic organization and the level of expression of genes such as bcr and calcyclin and c-fms protooncogene possibly involved in the molecular mechanisms underlying cell proliferation in hematopoietic cells. The data obtained are discussed with respect to the myeloproliferative disorder.

SINUS HISTIOCYTOSIS WITH MASSIVE LYMPHADENOPATHY - IMMUNOLOGICAL, CYTOGENETIC AND MOLECULAR STUDIES

SummaryWe describe a case of “sinus histiocytosis with massive lymphadenopathy” (SHML) studied by immunohistochemical, cytogenetic and molecular analysis. The immunophenotyping showed that the lymph node histiocytes were strongly positive for the S-100 protein and MoAb LeuM3, OKM5, KP1 and DRC-1; a portion of these cells was also positive for OKT6 and Leu3A, suggesting a possible relationship with the veiled cells, which represent an intermediate step in the pathway from the Langerhans cell to the interdigitating reticulum cell. Cytogenetic analysis showed a normal prevalent clone and a small hypodiploid clone and the molecular study showed no detectable involvement of the c-fms proto-oncogene, which is related to monocyte/macrophages. Unfortunately all these data do not seem sufficient to define the benign or neoplastic nature of the disease. Further investigations, immunophenotypical, cytogenetic and molecular, are needed to elucidate the pathogenesis of the disease, especially for more aggressive cases or for cases with unfavorable evolution.

The oncogenic 30 and 69 bp deletion variants of the EBV LMP-1 gene are common in HIV-negative lymphoproliferations, both malignant and benign

BACKGROUND In vitro studies have shown that the 30 and 69 base pair (bp) deletion variants of the latent membrane protein (LMP)-1 gene of the Epstein-Barr virus (EBV) have a higher transforming capacity than the wild-type variant. In recent years these studies have triggered an in vivo search for such potentially oncogenic variants in lymphoid tissues. PATIENTS AND METHODS We used polymerase chain reaction (PCR) to investigate the prevalence of LMP-1 gene variants in EBV-positive lymph nodes from 60 HIV-negative Italian patients with benign and malignant lymphoid disorders. RESULTS The 30 bp variant was detected in 10 of 39 (25.6%) malignant lymphomas but also in 4 of 13 (30%) reactive lymphadenitis with follicular hyperplasia. Of note is the fact that the 69 bp variant was detected in three cases of malignant lymphoproliferation but also in two cases of localized Castlemans disease of hyalin vascular type. CONCLUSIONS The molecular detection of the oncogenic variants of the LMP-1 gene in a lymph node biopsy as an indicator of the aggressiveness of the EBV-associated lymphoproliferative disease must be considered with caution. The relatively high frequency of the 69 bp variant in our series compared with that reported in the literature probably reflects a different incidence of LMP-1 variants in healthy populations from different geographical areas.