Blastic mantle cell lymphoma associated with Burkitt-type translocation and hypodiploidy.

Two elderly men with stage IV mantle cell lymphoma (MCL) rapidly developed a leukaemic phase with unusually high blast counts that proved fatal. One lymph node biopsy showed diffuse MCL, the other blastic morphology. In addition to t(11;14), there were t(8;14) and t(1;19) in case 1 and dup(8)(q24q13) in case 2. Fluorescence in situ hybridization revealed genomic fusion of IgH/MYC genes in case 1 and an extra copy of C-MYC gene in case 2. The genomic alteration of C-MYC oncogene is probably implicated in the blastic transformation and aggressive behaviour of the disease.

CD56+/CD4+ lymphomas and leukemias are morphologically, immunophenotypically, cytogenetically, and clinically diverse.

CD56, a neural adhesion molecule, is a marker of natural killer (NK) lymphocytes as well as a subgroup of CD8+ T cells. Normal lymphocytes with a CD56/CD4 phenotype are scarce. Physiologic increases may occur in patients with immunosuppression, chronic inflammation, and autoimmune disorders. We report 4 cases of lymphomas/leukemias with the unusual CD56/CD4 phenotype. Two were of T-cell and 2 of true NK-cell origin. The T-cell lymphomas had large granular lymphocyte morphologic features and splenomegaly. One patients had a benign course; the other died within months of the leukemia diagnosis. The 2 NK cell lymphomas had blastic morphologic features, initially involved skin, and had a very aggressive clinical course; 1 patient died of acute leukemia, and 1 had recurrence after bone marrow transplantation. Cytogenetic analyses did not show a consistent pattern of abnormalities. The NK lymphoma with acute leukemia had a t(2;5) but was CD30- and anaplastic lymphoma kinase negative. Although CD56+/CD4+ lymphomas/leukemias are a heterogeneous group, there may be a distinct subgroup of NK lymphoblastoid lymphomas of the skin, judging from our cases, as well as those previously reported.

Chromosomal analyses of 52 cases of follicular lymphoma with t(14;18), including blastic/blastoid variant.

We have identified 52 patients of follicular lymphoma (FL) with t(14;18)(q32;q21). Histologically, the lymphomas were placed into six groups according to their cellular composition and growth pattern. Chromosome analysis revealed that all cases but one had additional secondary chromosomal abnormalities. The most frequent numerical aberrations were gains of chromosomes 7 (38%), X (36%), 5 (15%), 12 (15%), 18/der(18)t(14;18) (25%), and 21 (15%). Structural abnormalities of chromosome 1 were seen in 19 tumors (36%) affecting both arms with breakpoints clustered at 1p36. Other structural abnormalities included partial deletions of 6q, 10q, and 13q. Breakpoint at 8q24 was seen in four cases. The chromosome aberrations were correlated with the morphological subtypes of follicular lymphoma. Gain of chromosome 7 appeared to be associated with follicular large cell lymphoma. The incidence of trisomy 5 and 12, and 13q- was higher in follicular lymphoma with aggressive histological features than in low-grade lymphoma. In addition, complexity of the karyotype and high degree of polyploidy increased with the grade. The most valuable cytogenetic markers in the t(14;18) lymphomas are those involving 8q24 which was found exclusively in the blastic/blastoid variant FL. Therefore, chromosome analysis in relation to histologic pattern of follicular lymphoma can provide additional information in predicting tumor evolution and transformation to a higher-grade malignancy.

Reduction of ischemia-reperfusion syndrome after abdominal aortic aneurysmectomy by N-acetylcysteine but not mannitol.

BACKGROUND: Abdominal aortic aneurysmectomy results in a general ischemia-reperfusion syndrome accompanied by an acute rise in mean pulmonary artery pressure (MPAP). Severe and sometimes fatal postoperative cardiopulmonary complications have been described. METHODS: This pilot study examined whether N-acetyl-cysteine (NAC), a precursor of the most important physiological antioxidant glutathione (reduced form: GSH; oxidized form: GSSG), or the hydroxyl radical scavenger mannitol (MAN) modifies these events. The patients received 150 mg/ kg b.m.NAC (n = 9) 30 minutes before infrarenal aortic clamping or 500 mg/kg b.m. MAN (n = 10) 10 minutes before declamping. 11 patients had no additional treatment (control). RESULTS: In the control group, a significant increase in plasma levels of oxidized glutathione and lipid peroxides was observed after declamping. Additionally, a significant increase in plasma levels of the stable metabolites of thromboxane (TXB2) and prostacyclin (6-keto-PGF1 alpha) was measureable after declamping. There was a transient increase in MPAP and pulmonary vascular resistance (PVR), both of which returned to normal values within 20 minutes. Six hours after surgery, pulmonary dysfunction was manifest by increase in the intrapulmonary shunt fraction. Relative to the control group, NAC pretreatment led to a complete lack of changes in plasma lipid peroxide, thromboxane and prostacyclin levels after declamping; there was a significant increase in plasma GSH concentration persisting over a period of 12 hours. MPAP, PVR and Qs/QT values were unchanged. MAN pretreatment showed similar effects on the parameters obtained in the acute phase after declamping like the control group. CONCLUSIONS: Pretreatment with NAC, but not mannitol, may help prevent ischemia-reperfusion syndrome following aortic clamping.

Double minute chromosomes contain amplified c-myc oncogene sequences in acute myeloid leukemia.

We describe two elderly male patients with acute myeloid leukemia transformed from myelodysplastic bone marrow. Neither patients had a history of prior exposure to mutagenic agents or other malignancies. Chromosome analysis at the time of initial diagnosis revealed 47,XY,del(5)(q14q33),+21 in patient 1 and 45,XY,add(1)(q23),-5,del(8)(p11.2p23),der(17)t(5;17)(p12;p11.2) in patient 2. In addition, numerous copies of double minute chromosomes were seen in both patients. We used fluorescence in situ hybridization to identify the amplified sequences presumed to represent the dmins in the leukemic cells. In both cases, it appeared that the dmins were derived from specific amplification of c-myc oncogene.

A method for measuring lymphocyte proliferation in mixed lymphocyte cultures using a nuclear proliferation antigen, Ki-67, and flow cytometry.

The mixed lymphocyte culture procedure using tritiated thymidine (3H-TdR) incorporation is time consuming and labor intensive, therefore costly. With the use of a fluorescent antibody to a human nuclear proliferation antigen, Ki-67, and flow cytometry, mixed lymphocyte cultures on 20 families of renal and bone marrow transplant patients and normal controls were performed. In this method for measuring lymphocytic proliferation, previously developed by the authors, the entire culture and staining procedures are performed in microculture plates. Finally, the cell suspensions are aspirated with a microsampler to be analyzed by a flow cytometer. Excellent correlation of the percentage of Ki-67-positive cells and the counts per minute (CPM) of 3H-TdR incorporated into the DNA was obtained. This method eliminates the use of radioactive labels, is less time consuming, and yields results two to three days earlier than the radioactive method. In addition, the authors dual-labeled the lymphocyte nuclei with Ki-67 and propidium iodide (Ki-67/PI). This permitted the comparison of the appearance of nuclear antigen with the various phases of the cell cycle.

B lymphocytic lymphoma (large cell) of possible splenic marginal zone origin presenting with prominent splenomegaly and unusual cordal red pulp distribution.

Two cases of large cell lymphoma, B-cell type, primarily involving the red pulp of the spleen rather than the white pulp are described. A number of unusual features suggest that this may be a lymphoma originating from a distinct splenic B-cell lymphocyte whose origin may be the marginal zone of the spleen or the splenic cords. The patients presented with splenomegaly, cytopenias, and no peripheral lymphadenopathy. The gross appearance of the spleens was beefy red without tumor nodules. The tumor cells were primarily in the splenic cords and surrounding residual normal white pulp. There was a minimal hemic phase. The tumor cells had abundant cytoplasm, surface IgM, IgD, kappa, and FC receptors, tartrate-resistant acid phosphatase, but no alkaline phosphatase or interleukin-2 receptors. They had a similar DNA aneuploidy. The most unusual feature was that tumor cells in both cases had phagocytic properties. These lymphomas may be clinically more indolent than their follicular center counterparts.

A flow cytometric method for measuring lymphocyte proliferation directly from tissue culture plates using Ki-67 and propidium iodide.

A new method for measuring lymphocyte proliferation in response to mitogens and allogeneic cells without using radiolabelling is described. It utilizes flow cytometry and the monoclonal antibody, Ki-67, which detects a nuclear proliferation antigen. The entire test is performed in standard, 96-well tissue culture plates. Stable, clean nuclear suspensions rather than whole cells were used to avoid non-specific staining. The nuclei were stained by the indirect fluorescent method. Simultaneous measurements of DNA content were possible by dual staining with propidium iodide (PI). The percentage of Ki-67-positive nuclei correlated well with [3H]thymidine uptake and morphologic quantitation of blasts. This method avoids use of radioactive material and is less time consuming.

Flow cytometric purification of Alzheimer's disease amyloid plaque core protein using thioflavin T.

Amyloid plaque core protein (APCP) of Alzheimer's disease obtained from brain tissue homogenate is difficult to recover in pure form, primarily because of contaminating lipofuscin (LF) granules. Thioflavin T, a fluorescent dye previously used to stain amyloid, was found to bind to APCP but not to lipofuscin. The latter, however, is autofluorescent. Fluorometric studies showed that at 370 nm excitation APCP has a maximal emission at 418 nm, whereas the autofluorescent LP has a maximal emission at 450 nm. This difference in emission permitted the use of a flow cytometer-sorter (FACS 440) for purification of APCP. APCP particles fluoresced distinctly from LF granules on the log blue fluorescence parameter. The two entities were sorted using forward light scatter versus fluorescence. A collection apparatus was designed and prepared to facilitate the collection of large volumes of sheath fluid and particles and to minimize fragmentation of particles during the collection process. The sorted APCP fraction was 98% pure. This work demonstrates how old dyes can be used to perform new tricks and provide a useful method for separating complex protein.

Extramedullary (skin) presentation of acute monocytic leukemia resembling cutaneous lymphoma: morphological and immunological features.

Acute monocytic leukemia has been noted to exhibit a predilection for extramedullary involvement (gums, skin, and lymph nodes) at presentation. More unusual is the occurrence in an extramedullary site in the absence of bone marrow involvement. A case is reported with initial presentation in skin preceding a subsequent evolution to a leukemic phase by one year. The skin tumor was initially diagnosed and treated as a lymphoma. A second skin tumor, biopsied one year later was immunophenotyped as a T cell lymphoma using a screening panel of antisera (OKT4 positive, OKMI negative). Shortly thereafter a monocytic leukemia (M5) was discovered. Using a larger panel of antisera and enzyme markers on the second skin biopsy confirmed the monocytic rather than lymphocytic nature of the skin tumor. This case illustrates the importance of using an expanded panel of monoclonal antisera in certain hematopoietic tumors.

Storage and transportation of lymphoid tissue for immunophenotyping.

Immunoperoxidase staining of frozen sections is a cost-effective technic for immunophenotyping cells of lymphoid tissue. Because this procedure is not performed in many institutions, a simple method to transport fresh tissue to centers performing these studies is required. Tissues in saline at refrigerator temperature may be successfully transported. In addition, in order to minimize laboratory expenses, lymphoid tissue can be kept refrigerated in saline until permanent sections are examined and immunodiagnostic procedures become necessary. In this study reproducible immunophenotyping of 12 samples of lymphoid tissue stored up to seven days was achieved.

Purification, ultrastructure, and chemical analysis of Alzheimer disease amyloid plaque core protein.

Isolation of Alzheimer disease amyloid plaque core protein (APCP) was carried out by repetitive NaDodSO4/EDTA/sucrose extractions and by Ficoll-400 density-gradient centrifugations. The enriched APCP-Ficoll interface was labeled with the fluorochrome thioflavin T and separated from the contaminating lipofuscin by fluorescence-activated cell sorting. Electron microscopy demonstrated that APCP is made of two different kinds of filaments measuring 5.5-6 nm and 10-12 nm, respectively, and of variable length. Purified APCP and lipofuscin were chemically modified by performic acid oxidation. The amino acid composition of APCP revealed a high content of glycine and valine (30%) and 1% cysteine. By contrast, the protein moiety of the copurified lipofuscin contained 16% cysteine. The amino acid composition of APCP did not resemble that of any known protein.

Comparison of morphologic features and mitotic rate to cytometrically determined DNA content of poorly differentiated lymphocytic lymphomas.

A direct correlation between the percentage of cells in S phase of the cell cycle and the clinical behavior of lymphocytic lymphomas of low, intermediate, and high grade malignancy has been described. The histopathologist has used the mitotic rate and other morphologic criteria such as size of cells and nuclear characteristics as predictors/indicators of the aggressiveness of a tumor. We compared the S phase values of 22 cases of poorly differentiated lymphocytic lymphoma (PDL) of the B cell type, using flow cytometric measurement of DNA content, to morphologic features and mitotic rate (MR). The 22 cases were divided into 3 histologic groups: nodular PDL composed of small, cleaved lymphocytes (11 cases); follicular mantle zone lymphoma and those of intermediate differentiation (6 cases); and "blastic" PDL (5 cases). In Group 1 there was excellent correlation of MR, percentage of cells in S phase, and proportion of large cells (transformed lymphocytes) per high power field (HPF). In Group 2, this correlation was not found between MR and percentage of cells in S phase in five of the six cases. The high S phase in this group did correlate with the large proportion of large cells found primarily in pseudofollicular proliferation centers and in remnants of true follicular centers. These cells may have a prolonged S phase and thus fewer mitoses were seen. In Group 3, although both MR and S phases were high, a direct correlation between them as noted in the Group 1 cases was not seen, but an excellent correlation of the high S phase and the number of blasts was present. The fact that three of the five patients in this group died rapidly (within less than 2 years of presentation) and the two survivors were experiencing rapid progression of disease, supports the concept that this group represents a clearly different, more aggressive subclass of PDL.

B-cell lymphomas morphologically resembling T-cell lymphomas.

Seven cases of B-cell lymphoma that morphologically resembled T-cell lymphoma are described. These cases are of four morphologic types: atypical poorly differentiated lymphocytic lymphoma (PDLL) with convoluted nuclei, "Lennert's" lymphoma, mixed lymphocytic-"histiocytic" lymphoma with large variation in size of abnormal cells, and "histiocytic" lymphoma with large multilobed nuclei. These cases add further support to the belief that morphologic criteria alone are not sufficient for accurate immunologic classification of the malignant lymphomas since they may represent a distinct clinicopathologic entity.

In vitro neutrophil-erythrocyte rosette formation mediated by a serum factor (IgG).

In vitro neutrophil-erythrocyte rosette (NER) formation occurred in the peripheral blood of an elderly man. This caused problems in cross-matching for blood transfusion initially but was resolved by performing crossmatches at 37 degrees C because this phenomenon was temperature-dependent. NER formation was independent of complement and of the type of anticoagulant used. NERs were induced using normal control cells with the patient's plasma, serum, and the IgG fraction of serum. The rosetting factor was adsorbed by heterologous group-specific erythrocytes, but not by leukocytes. No neutrophil antibodies were identified.

True histiocytic lymphoma. A report of four cases.

Clinical, morphologic, cytochemical, immunologic, and ultrastructural features of four cases of true histiocytic lymphoma are described. The neoplastic cells were large, ranging from 20 to 45 mu in diameter with round, folded, or convoluted nuclei, and abundant eosinophilic cytoplasm. They exhibited diffuse nonspecific esterase activity. Diffuse acid phosphatase activity was present in two cases so tested. Muramidase activity was present in half of the cases. Finely granular PAS-positive material was seen in the cytoplasm. Methyl green-pyronin positivity was variable. An occasional neoplastic cell showed erythropagocytosis in one case. Malignant cells either contained no cytoplasmic immunoglobulins (three cases) or had immunoglobulins of multiple classes (one case). Surface markers were studied in two cases; they were absent in one case, and were of multiple classes in another case. Ultrastructurally the neoplastic cells had lysosomal granules in three cases so examined, and phagolysosomes, phagocytized material and residual bodies in one of three cases so studied. Patients ranged in age from 28 to 60 years. Two patients had extralymphatic tumors. Survival of more than 5 years was seen in one patient.

Natural killer and suppressor T-cell chronic lymphocytic leukemia.

A patient with low-grade lymphocytosis, splenomegaly, and neutropenia, but adequate myeloid leukogenesis, was found to have chronic lymphocytic leukemia, which represented a clonal proliferation of a distinct T-lymphocyte subset. The lymphocytes did not form E rosettes but had an OKT3+, OKT4+, OKT6+, OKT8+, OKT11+, HNK-1+, HNK-36+, OKIa1+, OKM1+ phenotype and functionally had suppressor and natural killer activity. Morphologically, they were large granular lymphocytes, which were strongly acid phosphatase positive and nonspecific esterase negative. They did not respond to mitogens, or to allogeneic cells. Initially, the spleen appeared to be the most involved organ and, judging from the high proportion of leukemic splenic lymphocytes in the S and G2/M phases of the cell cycle, was also the organ of origin of the leukemic cells. Only a few leukemic cells in the blood and bone marrow were in S and G2/M phases. After splenectomy, the lymphocyte count rose considerably and the bone marrow became progressively more infiltrated by tumor nodules. One year after diagnosis, the patient was started on chemotherapy because of progressive anemia. He responded to the chemotherapy by normalization of the hemoglobin and neutrophil count and had a moderate decrease in the bone marrow involvement and peripheral lymphocytosis.

The value of immunoperoxidase studies in the diagnosis of 2 cases of acute leukaemia.

2 cases of acute leukaemia in which the precise diagnosis was established using the immunoperoxidase technique on particle sections, a method not usually employed for acute leukaemias, are reported. Morphologically and cytochemically these cases were initially diagnosed as acute megakaryoblastic (case 1) and acute monocytic (case 2) leukaemia. Based on the immunoperoxidase studies, these diagnoses were corrected to DiGuglielmo's disease (case 1) and plasma cell leukaemia (case 2).

Acute megakaryoblastic Leukemia.

Acute megakaryoblastic leukemia is a rare and rapidly fetal disorder characterized by extensive proliferation of megakaryoblasts and atypical megakaryocytes in bone marrow and extramedullary sites, thrombocytopenia and only a few blasts in peripheral blood. Three cases of this leukemia were studied morphologically, cytochemically, and electron microscopically. The leukemia blasts varied from 10-20 mu in diameter, had coarsely reticular nuclear chromatin, and numerous cytoplasmic projections and vacuoles. Except for intense granular PAS positivity and diffuse acid phosphatase reactivity, all of the usual cytochemical stains were negative. The blasts had no specific differentiating features identifying them as megakaryoblasts even at the ultrastructural level. In such instances demonstration of platelet peroxidase will confirm the megakaryocytic origin. All three patients in this series were men and all died within 90 days. Two patients also had other malignancies.