Vassiliki Kaloutsi

Primary gastrointestinal non-Hodgkin's lymphoma: A clinicopathologic study of 128 cases in Greece. A Hellenic Cooperative Oncology Group study (HeCOG)

The aim of this retrospective study was to illustrate the clinicopathologic data and the treatment results in patients with primary gastrointestinal tract non-Hodgkins lymphoma (GI NHL). Among 810 patients with NHL, 128 cases (15.8%) were diagnosed as primary GI tract NHL. There were 79 males and 49 females with median age of 62 years. The most common primary site was the stomach (68%). Overall, 67.2% of the patients were in stages I – II, and 32.8% in stages III – IV. Simultaneous involvement of the GI tract and other extranodal sites was observed in 26 patients (20%). Extranodal marginal zone B-cell lymphoma (MZBL) (i.e., low-grade lymphoma of mucosa-associated lymphoid tissue type) accounted for 48.4% of lymphomas. Aggressive lymphomas (diffuse large B-cell lymphoma [DLBL]) accounted for 44.5%. Eighty-three patients (67.5%) achieved complete response (CR), either by surgery (43/43 patients, 17 with DLBL and 25 with MZBL) or by primary chemotherapy (40/64 patients, 22 with DLBL and 17 with MZBL). Sixty-two patients remain in CR; 33/43 after surgical resection (13/17 with DLBL and 20/25 patients with MZBL), and 29/40 after only chemotherapy (18/22 with DLBL and 10/17 with MZBL). The major prognostic factor for outcome in the present study was the stage of the disease. Patients with localized lymphoma (stage I and II) had significantly longer DFS and OS (DFS and OS at 3-year: 83% and 87%, respectively) than patients with extended disease (stage III and IV) (DFS and OS at 3-year: 46% and 60%, respectively) (P < 0.0001). The International Prognostic Index (IPI) for patients with aggressive lymphomas was prognostic only for DFS (79% for low-risk patients [IPI score 0 – 1] vs 49% for higher risk groups [IPI score >1] at 3-year, P = 0.0131).

Cyclin D1 overexpression in multiple myeloma. A morphologic, immunohistochemical, and in situ hybridization study of 71 paraffin-embedded bone marrow biopsy specimens.

Cyclin D1 expression was evaluated by immunohistochemical analysis and biotin-labeled in situ hybridization (ISH) in a series of 71 decalcified, paraffin-embedded bone marrow biopsy specimens from patients with multiple myeloma (MM). Cyclin D1 messenger RNA (mRNA) overexpression was detected by ISH in 23 (32%) of 71 cases, whereas cyclin D1 protein was identified by immunohistochemical analysis in 17 (24%) of 71 specimens. All cases that were positive by immunohistochemical analysis also were positive by ISH. Statistically significant associations were found between cyclin D1 overexpression and grade of plasma cell differentiation and between cyclin D1 overexpression and extent of bone marrow infiltration. Our findings demonstrate the following: (1) ISH for cyclin D1 mRNA is a sensitive method for the evaluation of cyclin D1 overexpression in paraffin-embedded bone marrow biopsy specimens with MM. (2) ISH is more sensitive than immunohistochemical analysis in the assessment of cyclin D1 expression. (3) Cyclin D1 overexpression in MM is correlated positively with higher histologic grade and stage.

In Situ Hybridization and Reverse Transcription–Polymerase Chain Reaction for Cyclin D1 mRNA in the Diagnosis of Mantle Cell Lymphoma in Paraffin-Embedded Tissues

Mantle cell lymphoma (MCL) is characterized by the chromosomal translocation t(11;14), which involves rearrangement of the bcl-1 proto-oncogene to the immunoglobulin heavy chain gene and results in overexpression of cyclin D1 mRNA. In this study, we evaluated the diagnostic relevance of three methods that may be helpful in the diagnosis of MCL: in situ hybridization (ISH) and a stringent reverse transcriptase–polymerase chain reaction (RT-PCR) protocol for cyclin D1 mRNA, and immunohistochemistry for cyclin D1 protein. The study group included 37 paraffin-embedded specimens (25 from lymph nodes and 12 from extranodal tissues) from 30 patients. MCL diagnosis was performed according to the Revised European-American Classification of Lymphoid Neoplasms. Twenty-nine patients with non-MCL lymphoproliferative disorders comprised the control group. Biotin-labeled ISH was performed in 28 cases of MCL, 24 (86%) of which were found to be positive. As shown by ISH in extranodal tissues, cyclin D1 mRNA was present not only in neoplastic lymphoid cells, but in other cell types as well. For this reason, RT-PCR results were considered reliable for MCL diagnosis only on informative material (from tissues that do not normally express cyclin D1); this method was evaluated as positive in 16 of 18 (89%) MCL cases. Cyclin D1 immunopositivity was present in 20 of 29 (69%) MCL cases. No members of the control group were found to express cyclin D1 mRNA by either ISH or RT-PCR under the stringent conditions used. In conclusion, stringent RT-PCR for cyclin D1 expression can be helpful in MCL diagnosis in paraffin-embedded material from lymph nodes. ISH is a sensitive method for cyclin D1 mRNA detection; its sensitivity is superior to that of cyclin D1 immunohistochemistry and similar to that of the stringent RT-PCR used. ISH is very specific as well, clearly more specific than RT-PCR, because it allows the correlation of molecular findings with morphology. This method can be applied on all types of paraffin-embedded tissues and provides an accurate tool for MCL diagnosis.

Mismatch Repair Gene Expression in Malignant Lymphoproliferative Disorders of B-cell Origin

We investigated mismatch repair (MMR) gene expression in 31 lymphoid tissue specimens and bone marrow aspirates with malignant lymphoproliferative disorders of B-cell origin (25 cases of lymphoma and six cases of plasma cell myeloma). A multiplex RT-PCR assay was employed to assess the relative expression of the hMSH2, hMLH1 and hPMS1 genes, as compared to β -actin, which was used as an internal control of gene expression. MSH2 was further evaluated at the protein level by immunohistochemistry. The findings were compared to those of a control group of lymphoid tissue specimens without evidence of malignancy (n =6). Changes in MMR gene expression were observed in 10 out of 31 cases of the study group (32%). All three MMR gene transcripts were low in two out of six plasma cell myelomas, which had extensive bone marrow infiltration by neoplastic cells. The hMSH2 transcript was present in all cases of lymphoma, while the expression of hMLH1 and hPMS1 was significantly low in some large B-cell lymphomas (four and five out of 14 cases, respectively) and in mantle cell lymphomas of the blastoid type (two out of two cases). No MMR gene aberrations were found in seven cases of B-cell lymphocytic leukemia and two cases of mantle cell lymphoma of centrocyte-like type. These findings demonstrate that the expression rates of the hMSH2, hMLH1 and hPMS1 genes differ among various types of B-cell lymphoproliferative disorders, and suggest that MMR gene expression may be related to the natural history of these neoplasms. This study identified a higher incidence of MMR gene aberrations in lymphoma types characterized by aggressive biologic behavior, as compared to neoplasms with a more indolent course.

Acute appendicitis secondary to Enterobius vermicularis infection in a middle-aged man: a case report.

IntroductionAcute appendicitis due to Enterobius vermicularis is very rare, affecting mostly children. Whether pinworms cause inflammation of the appendix or just appendiceal colic has been a matter of controversy.Case presentationA Caucasian 52-year-old man was referred to our Emergency Department with acute abdominal pain in his right lower quadrant. The physical and laboratory examination revealed right iliac fossa tenderness and leukocytosis with neutrophilia. An open appendectomy was performed. The pathological examination showed the lumen containing pinworms. Two oral doses of mebendazole were administered postoperatively. The follow-up to date was without incident and he was free of symptoms one year after the operation.ConclusionThe finding of E. vermicularis in appendectomy pathological specimens is infrequent. Parasitic infections rarely cause acute appendicitis, especially in adults.One should keep in mind that the clinical signs of intestinal parasite infection may mimic acute appendicitis, although rare. A careful evaluation of symptoms such as pruritus ani, or eosinophilia on laboratory examination, could prevent unnecessary appendectomies.

An extremely rare case of synchronous occurrence in the larynx of intravascular lymphoma and in situ squamous cell carcinoma.

We present the first case of laryngeal intravascular lymphoma coexisting with in situ squamous cell carcinoma. The patient, a 53 years old man, presented with hoarseness starting a year ago and underwent laryngoscopy, which revealed two nodular lesions on his right vocal cord. The histological and immunohistochemical examination of the biopsy specimens established the diagnosis of in situ squamous cell carcinoma coexisting with intravascular lymphoma of T-cell origin. Taking in consideration all the available references, the larynx has not until now been reported as a primary site of involvement of intravascular (angiotropic) lymphomas, nor as a secondary location in the systematic course of this disease. Furthermore no cases have been reported in the literature, concerning the synchronous affection of the larynx by this lymphoma and in situ laryngeal carcinoma, or other type of neoplasm.

IgG multiple myeloma presented with ulcerative pyoderma gangrenosum

Pyoderma gangrenosum (PG) is an uncommon skin disorder of uncertain pathogenesis, characterized by a painful pustule or papulonodule, which spreads progressively and can rapidly break down to form an ulcer. PG is often associated with an underlying systemic disease such as inflammatory bowel disease, autoimmune disease or hematologic malignancy [1 – 3]. We present a case of IgG multiple myeloma associated with ulcerative PG at diagnosis. In May 2005, a 55-year-old female patient was admitted in our department because of anemia (Hb: 10 g/dL) and leukopenia (WBC: 1700610/L). She was also complaining for painful ulcers with papulopustules of 12 months’ duration, on both legs (Figure 1). Physical examination revealed also hepatomegaly of 6 cm below the right costal margin. Bone marrow aspiration and biopsy showed a 40% infiltration by plasma cells. A serum monoclonal IgGl paraprotein was detected by immunofixation with a total serum IgG level of 52.4 g/L. No cryoglobulins were detected. Flow cytometric analysis of bone marrow plasma cells showed l-clonality. Karyotypic analysis was normal. Skeletal survey revealed generalized osteopenia and osteolytic lesions of the skull. Cultures obtained from the skin lesions were negative. Histopathological examination of skin biopsy showed a neutrophilic inflammatory infiltrate in the dermis and hypodermis consistent with PG. A diagnosis of multiple myeloma (ISS stage II) associated with ulcerative PG was made and treatment with oral thalidomide (200 mg daily) and dexamethasone (40 mg for 4 days every 2 weeks) was started. A remarkable regression of the skin lesions was observed 5 weeks after therapy initiation and PG was healed completely. Regarding multiple myeloma, a partial remission according to EBMT criteria [4] was achieved after 3 months of therapy. Disease remains in plateau phase until now. PG is a non-infectious neutrophilic dermatosis that usually begins with sterile pustules, which rapidly progress to painful ulcer with undetermined violaceous borders. PG represents a skin lesion commonly overlooked and often misdiagnosed as an ulceration of circulatory, malignant or infectious origin. The correct diagnosis of PG is based on a history of an underlying disease, typical clinical presentation and histopathology as well as exclusion of other disorders that could lead to similar lesions [3]. Over half the cases of PG are associated with systemic disorders, most commonly inflammatory bowel disease, diabetes mellitus, autoimmune diseases (rheumatoid arthritis, spondyloarthropathy), paroxysmal nocturnal hemoglobinuria, myeloproliferative disorders and hematological malignancies such as multiple myeloma, non-Hodgkin’s lymphoma and acute myeloid leukaemia [1 – 3,5]. Various non-specific cutaneous manifestations have been described in association with multiple myeloma. These include protein deposition related skin lesions (amyloid, cryoglobulins), PG, leukocytoclastic vasculitis, Sweet’s syndrome and others [1,6]. The exact relationship between multiple myeloma and PG is unclear. A monoclonal serum

Synchronous occurrence of multiple malignant neoplasms in the uterus (adenocarcinoma of the endometrium, large B-cell lymphoma of the cervix).

Multiple primary malignancies of the uterus are extremely rare. We report a case of endometrial adenocarcinoma and cervical large B-cell lymphoma occurring simultaneously in a 64-year-old woman with uterine bleeding. Adenopathy, hepatosplenomegaly or bone marrow infiltration were not found. Both malignant neoplasms mentioned above were diagnosed incidentally on the specimen (total hysterectomy with bilateral salpingo-oophorectomy) removed for uterine leiomyomas.

Aberrant expression of myeloid and B cell markers in an aggressive multiple-site myeloid sarcoma

Dear Editor, A 45-year-old female patient presented to our center because of pain at the lumbar spine, since 3 months. Mild normocytic anemia (Hb 11.6 g/dL, Hct 34.5%) was found. Computed tomography (CT) scan revealed a hypodense lesion in the pancreatic head (diameter 20 mm), along with osteolytic findings, located to the manubrium of the sternum, the fifth lumbar vertebra, and the sacrum. No lymphadenopathy or hepatosplenomegaly was present. While investigating the primary focus of a possible neoplasm, biopsies were received from the sternum and two duodenal polypoid lesions. Bone marrow aspiration and trephine biopsy were negative for malignancy. After evaluation of the sternic and the duodenal lesions, the pathologist provided the diagnosis of myeloid sarcoma. The lesions were infiltrated by large neoplastic cells withmarked cytoplasm and irregularor egg-shaped nuclei. Immunohistochemically, tumor cells were positive for myeloperoxidase, lysozyme, terminal deoxynucleotidyl transferase, CD34, CD99, CD56, CD45, CD45RA, CD43, CD79A, CD10, CD38, HLA-DR, and negative for naphthol-ASDchloroacetate esterase, CD2, CD4, CD5, CD7, CD30, CD45RO, and elastase (Fig. 1). Therefore, the neoplastic population consisted of a unique cell population, which was a “hybrid” of a myeloid lineage precursor cell and of a more mature cell of B cell lineage. The patient underwent two cycles of acute myeloid leukemia (AML) induction treatment [idarubicin (10 mg/m), cytarabine (100 mg/m)] and one cycle of AML consolidation therapy [cytarabine (2 g/m), etoposide (100 mg/m)]. The temporal remission, as proven by the reduction of size of the pancreatic lesion (Fig. 1), and the negative intestinal biopsy lasted for 90 days after initial treatment. Although allogeneic stem cell transplantation was considered at first complete remission (CR), no suitable donor was found because the patient had no male or female siblings. A matched unrelated donor was not found either. Nevertheless, the disease relapsed to the central nervous system (presence of blasts to cerebrospinal fluid) with diplopia (located to vermis, hemispheres of the cerebellum, and leptomeninges) (Fig. 1) without bone marrow infiltration. Intrathecal chemotherapy [methotrexate 15 mg, cytarabine 40 mg, dexamethasone 4 mg (eight sessions)] was successful. The patient received radiotherapy (two sessions) and after the new relapse from the manubrium of the sternum and the bones (CT) with concomitant thrombosis of the right femoral and iliac veins (Doppler ultrasonography), salvage chemotherapywas given [idarubicin (12 mg/m), fludarabine (30 mg/m), cytarabine (2 g/m), granulocyte colony-stimulating factor (400 μg/m)]. The G. D. Kaiafa :V. Perifanis :M. D. Diamantidis (*) : V. Voulgaridou Department of Haematology, First Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, AHEPA General Hospital, 1 S. Kiriakidi St, 546 36 Thessaloniki, Greece e-mail: diamantidis79@yahoo.gr

Concurrent presentation of nodal myeloid sarcoma and bone marrow chronic lymphocytic leukemia/small lymphocytic lymphoma: a unique association

Myeloid sarcoma (MS), previously known as granulocytic sarcoma, is a rare, localized, tumor mass composed of myeloid precursor cells, with or without maturation, and occurring at an anatomical site other than the bone marrow (BM). Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), in contrast, is a B-cell hematological malignancy. We describe the first reported case of concurrent presentation of nodal MS and of BM CLL/SLL in the same patient. Fatal leukemic central nervous system infiltration was the final outcome. We provide possible explanations and investigate the pathophysiology of this unique, previously unreported co-morbidity.