Follicle Center Lymphoma (FCL) of the Lower Female Genital Tract (LFGT): A Novel Variant of Primary Cutaneous Follicle Center Lymphoma (PCFCL).

Primary cutaneous follicle center lymphoma has been distinguished from nodal follicular lymphoma (FL) based on genomic and clinical features. The nature of other extranodal FLs is not well defined. We report 15 cases of follicle center lymphoma involving the lower female genital tract. Cases were evaluated using an immunohistochemical panel for B-cell lymphoma, B-cell clonality, fluorescence in situ hybridization for BCL2 gene rearrangement, and next-generation sequencing. All patients had localized disease with no evidence of bone marrow involvement. Most cases (12/15, 80%) had a follicular pattern, at least focally. Large centrocytes were a prominent feature leading to concern for diffuse large B-cell lymphoma by referring pathologists. Neoplastic cells were positive for CD20 and BCL-6, while BCL-2 was positive in 2/15 (13%) cases. Fluorescence in situ hybridization for BCL2 gene rearrangement was negative in 10/11 (91%) cases. Next-generation sequencing performed in 10 cases revealed TNFRSF14 as the most frequently mutated gene in 6/10 (60%) cases. No case had CREBBP or KMT2D mutations as seen in nodal FL. None of the patients had progressive disease with durable complete remission achieved in 10/12 (83%) cases. The median follow-up period was 7.8 years (range: 0.2 to 20.5 y) with a 5-year overall survival of 100%. We conclude that follicle center lymphoma of the lower female genital tract is a novel variant of primary cutaneous follicle center lymphoma. Despite a frequent component of large cells, it is characterized by localized disease and low risk for dissemination. Awareness and recognition are important to distinguish these lesions from aggressive B-cell lymphomas.

Cyclic-AMP signalling, MYC and hypoxia-inducible factor 1α intersect to regulate angiogenesis in B-cell lymphoma.

Angiogenesis and MYC expression associate with poor outcome in diffuse large B-cell lymphoma (DLBCL). MYC promotes neo-vasculature development but whether its deregulation in DLBCL contributes to angiogenesis is unclear. Examination of this relationship may uncover novel pathogenic regulatory circuitry as well as anti-angiogenic strategies in DLBCL. Here, we show that MYC expression positively correlates with vascular endothelial growth factor (VEGF) expression and angiogenesis in primary DLBCL biopsies, independently of dual expressor status or cell-of-origin classification. We found that MYC promotes VEGFA expression, a correlation that was validated in large datasets of mature B-cell tumours. Using DLBCL cell lines and patient-derived xenograft models, we identified the second messenger cyclic-AMP (cAMP) as a potent suppressor of MYC expression, VEGFA secretion and angiogenesis in DLBCL in normoxia. In hypoxia, cAMP switched targets and suppressed hypoxia-inducible factor 1α, a master regulator of VEGFA/angiogenesis in low oxygen environments. Lastly, we used the phosphodiesterase 4b (Pde4b) knockout mouse to demonstrate that the cAMP/PDE4 axis exercises additional anti-angiogenesis by directly targeting the lymphoma microenvironment. In conclusion, MYC could play a direct role in DLBCL angiogenesis, and modulation of cAMP levels, which can be achieved with clinical grade PDE4 inhibitors, has cell and non-cell autonomous anti-angiogenic activity in DLBCL.

Epstein-Barr Virus-negative Marginal Zone Lymphoma as an Uncommon Form of Monomorphic Posttransplant Lymphoproliferative Disorder.

Monomorphic posttransplant lymphoproliferative disorders have been defined as lymphoid or plasmacytic proliferations that fulfill criteria for one of the B-cell or T/NK-cell neoplasms recognized in immunocompetent hosts in the current WHO Classification. Low-grade B-cell neoplasms have historically been excluded from this category, although rare reports of marginal zone lymphoma (MZL) have been described. We report 9 cases of posttransplant Epstein-Barr virus-negative MZL, all arising in solid organ transplant recipients (4 renal, 3 liver, 1 cardiac, and 1 liver, pancreas, and small bowel). Seven were extranodal MZL of mucosa-associated lymphoid tissue type, all of which had gastrointestinal involvement (4 colon, 1 duodenum, 1 stomach, and 1 oropharynx/base of tongue). Notably, the preferential involvement of intestine distinguishes posttransplant extranodal MZL from sporadic cases. Immunoglobulin light-chain restriction was seen in all cases, with polymerase chain reaction showing a monoclonal pattern in 7 of 8 cases with successful amplification of polymerase chain reaction products. A clonally unrelated recurrence was seen in one case. Next-generation sequencing identified recurrent mutations previously reported in MZL in 3/5 cases. MZL was diagnosed at least 1 year after solid organ transplant (median time to presentation, 84 mo; range, 13 to 108 mo). The median age was 44 (range, 9 to 73 y); the male: female ratio was 5:4. The mean follow-up was 33.4 months, with an indolent clinical course observed. A subset responded to reduction in immunosuppression and anti-CD20 therapy alone. These data support the designation of Epstein-Barr virus-negative MZL as an uncommon form of monomorphic posttransplant lymphoproliferative disorders.

CD5-negative Mantle Cell Lymphoma: Clinicopathologic Correlations and Outcome in 58 Patients.

Mantle cell lymphoma (MCL) represents 4% to 9% of all non-Hodgkin lymphomas and is characterized by CD5 and cyclin D1 expression and t(11;14)(q13;q32). However, about 5% of MCL lack CD5 expression and is poorly characterized. Here, we present 58 patients with CD5 negative (CD5) MCL and compared them with a group of 212 typical CD5 positive (CD5) MCL cases. There were 39 men and 19 women with a median age of 66 years (range, 36 to 88). Compared with CD5 positive (CD5) MCL patients, patients with CD5 MCL showed a lower male-to-female ratio (P=0.006) and a higher frequency of "bone marrow non-nodal" presentation (P=0.01). All other clinicopathologic features, including the frequency of SOX11 expression, were similar between the 2 groups. Treated with similar regimens, patients with CD5 MCL showed a significantly longer progression-free survival (PFS) (P=0.01) and a tendency for longer overall survival (OS; P=0.078) than CD5 positive (CD5) MCL patients. Univariate analysis showed of the well-known poor prognostic factors, only Mantle Cell Lymphoma International Prognostic Index was an inferior prognostic factor and blastoid/pleomorphic morphology and high Ki67 were not associated with prognosis in CD5 MCL patients. Multivariate Cox regression analysis showed CD5 expression was an independent prognostic factor for PFS (P=0.031) but not OS in MCL patients. In conclusion, the results suggest that patients with CD5 MCL have a more favorable prognosis than CD5 MCL patients, although the clinicopathologic features of both groups are largely similar. CD5 MCL may represent a distinct variant of MCL and needs to be included in the differential diagnosis of CD5 small B-cell lymphomas.

CD23 expression in mantle cell lymphoma is associated with CD200 expression, leukemic non-nodal form, and a better prognosis.

Mantle cell lymphoma (MCL) is usually CD23 negative, a feature helpful in distinguishing MCL from chronic lymphocytic leukemia/small lymphocytic lymphoma. However, a subset of MCL cases can be CD23+. Limited data are available regarding the clinicopathological features and prognosis of patients with CD23+ MCL. In this study, we reviewed 798 cases of MCL and identified 103 (13%) that were CD23+ by flow cytometry, all of which were positive for cyclin D1 and/or associated with CCND1/IGH. In all cases of CD23+ MCL, CD23 expression was dim partial or dim, unlike moderate to bright CD23 expression observed in chronic lymphocytic leukemia/small lymphocytic lymphoma. The clinicopathological features and outcome of patients with CD23+ MCL were compared with 240 patients with typical MCL negative for CD23. Patients with CD23+ MCL more often had an elevated leukocyte count (33% versus 18%, P = .009), bone marrow involvement (89% versus 78%, P = .02), stage 4 disease (87% versus 77%, P = .03), and a leukemic presentation (42% versus 11%, P = .0001). CD23+ MCL was also more often positive for CD200 (17% versus. 4.6%, P = .0005) and less commonly positive for SOX11 (55% versus. 74%, P = .027). All other clinicopathological features were similar. With similar treatment regimens and observation times, patients with CD23+ MCL had a significant better overall survival (P = .02) and progression-free survival (P = .029). In conclusion, CD23 expression was observed in 13% of MCL cases and is associated with a better prognosis in patients with MCL. CD23 is associated with leukocytosis, a leukemic presentation, bone marrow involvement, CD200 expression, and a lower frequency of SOX11 positivity.

SOX11-negative Mantle Cell Lymphoma: Clinicopathologic and Prognostic Features of 75 Patients.

Studies have suggested that SOX11 expression has prognostic implications in patients with mantle cell lymphoma (MCL), but the data are controversial. In this study, we describe the clinicopathologic and prognostic features of 75 patients with SOX11-negative MCL. Compared with patients with SOX11-positive MCL, SOX11-negative MCL patients more frequently had leukemic non-nodal disease (21% vs. 4%, P=0.0001). SOX11-negative MCLs more often showed classic morphology (83% vs. 65%, P=0.005), were more often positive for CD23 (39% vs. 22%, P=0.02) and CD200 (60% vs. 9%, P=0.0001), and had a lower proliferation index (Ki67 23% vs. 33%, P=0.04). Overall survival (OS) was not significantly different between patients with SOX11-negative versus SOX11-positive MCL (P=0.63). High Ki67 index and blastoid/pleomorphic morphology were associated with shorter OS in both SOX11-negative (P<0.05) and SOX11-positive MCL groups (P<0.05). A high Mantle Cell Lymphoma International Prognostic Index (MIPI) predicted poorer prognosis in patients with SOX11-negative MCL (P<0.0001), but not SOX11-positive MCL (P=0.09). Nodal involvement and stage III/IV disease were associated with poorer outcome in patients with SOX11-positive MCL (P=0.03 and 0.04, respectively), but not SOX11-negative MCL (P=0.88 and 0.74, respectively). In summary, SOX11-negative MCL is characterized by more frequent leukemic non-nodal disease, classic morphology, more frequent expression of CD23 and CD200, and a lower Ki67 index. Prognostic factors in patients with SOX11-negative MCL include morphology, Ki67 index, and MIPI score.

CD10-positive mantle cell lymphoma: clinicopathologic and prognostic study of 30 cases.

Mantle cell lymphoma is usually negative for CD10 which is useful in distinguishing MCL from other CD10 + B cell lymphomas. Here we assessed the clinicopathologic features of 30 cases of CD10+ MCL, the largest series to date in the English literature, and compared them with a group of 212 typical MCL cases (CD5+, CD10-negative, CD23-negative, cyclin D1+). The 30 patients with CD10+ MCL included 17 men and 13 women with a median age of 68 years. Compared with CD10-negative MCL, patients with CD10+ MCL showed a lower male predominance (p = 0.01), more often had a diffuse growth pattern (p = 0.04) and blastoid/pleomorphic morphology (p < 0.0001), and more often showed BCL6 expression (p = 0.009). In all MCL patients, CD10 expression was not associated with overall survival (OS) (p = 0.16). However, in more aggressive subsets of MCL patients including those with high Ki67 (> 60%), blastoid/pleomorphic morphology, or high MCL International Prognostic Index (MIPI), CD10 expression was associated with a worse OS (p = 0.003, 0.04, and 0.001, respectively). High Ki67 (> 60%), blastoid/pleomorphic morphology, and high MIPI were also been identified as poor prognostic factors patients with in CD10+ MCL (p = 0.001, 0.0003, and 0.01, respectively). In summary, CD10+ MCL more often has a diffuse growth pattern, blastoid/pleomorphic morphology, and BCL6 expression. In MCL patients with a high Ki-67 (> 60%), blastoid/pleomorphic morphology, or high MIPI, CD10 expression contributes to an even worse prognosis. MCL should be included in the differential diagnosis of CD10 + B cell lymphomas.

CD30 expression and prognostic significance in R-EPOCH-treated patients with diffuse large B-cell lymphoma.

A few recent studies investigated the prognostic impact of CD30 expression in diffuse large B-cell lymphoma (DLBCL) patients treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone. No study has evaluated the significance of CD30 expression in DLBCL patients treated with rituximab, etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin (R-EPOCH). In a group of 97 patients with DLBCL and high-risk features who received R-EPOCH induction therapy, we studied CD30 expression by immunohistochemistry using different cutoff values (>0% and ≥20% of lymphoma cells, respectively) and correlated with prognosis. CD30 expression was detected in 24 (25%) cases using a cutoff greater than 0% and in 12 (12%) cases using a cutoff of 20% or greater. The clinicopathological features were similar between CD30+ and CD30-negative groups. A major difference was that MYC rearrangement was infrequent in the CD30+ group: 2 (9%) of 23 in CD30+ versus 25 (35%) of 72 in CD30-negative group (P=.02). CD30 expression was not associated with germinal center B-cell-like (GCB) or non-GCB type. Overall survival (OS) was not significantly different between patients with CD30+ and patients with CD30-negative DLBCL, either for all patients or for the subset of patients without MYC rearrangement, regardless of cutoff (P>.05). CD30 expression was not associated with OS in either GCB or non-GCB subtype (P>.05, > 0% cutoff). In conclusion, CD30 expression was detected in up to 25% of cases of DLBCL and was more frequent in tumors without MYC rearrangement. CD30 expression was not associated with OS in R-EPOCH-treated de novo DLBCL patients.

Side scatter versus CD45 flow cytometric plot can distinguish acute leukaemia subtypes.

BACKGROUND & OBJECTIVES: Flow cytometry is an important tool to diagnose acute leukaemia. Attempts are being made to find the minimal number of antibodies for correctly diagnosing acute leukaemia subtypes. The present study was designed to evaluate the analysis of side scatter (SSC) versus CD45 flow dot plot to distinguish acute myeloid leukaemia (AML) from acute lymphoblastic leukaemia (ALL), with minimal immunological markers. METHODS: One hundred consecutive cases of acute leukaemia were evaluated for blast cluster on SSC versus CD45 plots. The parameters studied included visual shape, CD45 and side scatter expression, continuity with residual granulocytes/lymphocytes/monocytes and ratio of maximum width to maximum height (w/h). The final diagnosis of ALL and AML and their subtypes was made by morphology, cytochemistry and immunophenotyping. Two sample Wilcoxon rank-sum (Mann Whitney) test and Kruskal-Wallis equality-of-populations rank tests were applied to elucidate the significance of the above ratios of blast cluster for diagnosis of ALL, AML and their subtypes. Receiver operating characteristic (ROC) curves were generated and the optimal cut-offs of the w/h ratio to distinguish between ALL and AML determined. RESULTS: Of the 100 cases, 57 of ALL and 43 cases of AML were diagnosed. The median w/h ratio of blast population was 3.8 for ALL and 1 for AML (P<0.001). ROC had area under curve of 0.9772.The optimal cut-off of the w/h ratio for distinction of ALL from AML was found to be 1.6. INTERPRETATION & CONCLUSIONS: Our findings suggest that if w/h ratio on SSC versus CD45 plot is less than 1.6, AML may be considered, and if it is more than 1.6, ALL may be diagnosed. Using morphometric analysis of the blast cluster on SSC versus CD45, it was possible to distinguish between ALL and AML, and their subtypes.

Prognostic impact of history of follicular lymphoma, induction regimen and stem cell transplant in patients with MYC/BCL2 double hit lymphoma.

MYC/BCL2 double hit lymphoma (DHL) has been the subject of many studies; however, no study has systemically compared the clinicopathologic features and prognostic factors between patients with de novo disease versus those with a history of follicular lymphoma (FL). In addition, the prognostic importance of several other issues remains controversial in these patients. In this retrospective study, we assess 157 patients with MYC/BCL2 DHL including 108 patients with de novo disease and 49 patients with a history of FL or rarely other types of low-grade B-cell lymphoma. Patients received induction chemotherapy regimens including 61 R-CHOP, 31 R-EPOCH, 29 R-Hyper-CVAD, and 23 other regimens. Thirty-nine patients received a stem cell transplant (SCT) including 31 autologous and 8 allogeneic. Sixty-two patients achieved complete remission (CR) after induction chemotherapy. Median overall survival (OS) was 19 months. Clinicopathologic features were similar between patients with de novo tumors versus those with a history of FL (P > 0.05). Using multivariate analysis, achieving CR, undergoing SCT, stage and the International Prognostic Index were independent prognostic factors for OS. Stem cell transplantion was associated with improved OS in patients who failed to achieve CR, but not in patients who achieved CR after induction chemotherapy. In conclusion, patients with MYC/BCL2 DHL who present with de novo disease and patients with a history of FL have a similarly poor prognosis. Achievement of CR, regardless of the induction chemotherapy regimen used, is the most important independent prognostic factor. Patients who do not achieve CR after induction chemotherapy may benefit from SCT.

An Affordable, Indigenous Polarizer-Analyser System with Inbuilt Retardation Plate Function to Detect Birefringence using 3D Glasses: An Experience.

INTRODUCTION: Polarizing microscope plays a vital role in few but unique situations. A pair of cross polarizers is used to confirm the presence of birefringent substances. Also, a red retardation plate is needed to evaluate the sign of birefringence. However, a polarizing microscope especially with retardation plate is very expensive. Thus, an affordable yet effective substitute using the 3D Polaroid glasses used for '3D movies' would enable widespread use of the polarizing system. AIM: To study the use of 3D polaroid glasses procured from cinema halls in detecting birefringence substances and to study the red retardation plate function in them. MATERIALS AND METHODS: Passive 3D Polaroid glasses were procured from cinema halls. They were arranged in aspecific manner to obtain polarized light. Red retardation plate function can be obtained by changing the arrangement of the glasses. These glasses were used with various available models of different light microscope manufacturers. Various specimens observed included amyloid deposits, woven and lamellar bone, skeletal muscle striations, urate crystals, cholesterol crystals, suture material and glove powder. The comparison was based on subjective interpretation of intensity and quality of birefringence. Sign of birefringence was also determined whenever relevant. RESULTS: The birefringence observed by our system was comparable to the commercially available polarizing system with respect to intensity and quality. Also, there were no false positive /negative results when compared with the commercial Polarizing microscope. Moreover, the system had an inbuilt red retardation plate to determine sign of birefringence. CONCLUSION: The system is efficient, cheap, easily accessible, portable and compatible with all models of light microscopes.

Blastic Phase of CML with Microfilaria: A Rare Case Report.

Filariasis is a major public health concern in tropical and subtropical countries including India. There have been very few case reports of incidental filariasis in the bone marrow aspirate smears in patients with hematological malignancies. We present a case of blastic phase of chronic myeloid leukemia (CML) with associated filariasis with monocytosis. Such an association, to the best of our knowledge, is hitherto unreported. Moreover, eosinophilia was not a feature in our case. A 37-year-old male, diagnosed case of CML, presented with low grade fever, weight loss and abdominal distension for one month. Physical examination revealed massive splenomegaly and hepatomegaly. However, there was no lymphadenopathy. His hemoglobin was 10.5 g/dl, total leukocyte count was 52.31x 109 / L with platelet count of 30x 109/L .Differential leukocyte count on peripheral smear showed 21% blasts, 30% polymorphs, 16% lymphocytes, 1% myelocyte, 1%metamyelocyte, 30%monocytoid cells and 1% eosinophils. Bone marrow aspirate smears were diluted with peripheral blood and showed blasts and monocytoid cells constituting 25% and 15% of marrow nucleated cells respectively. In addition, occasional microfilaria of Wuchereria bancrofti were also seen both in the peripheral blood and aspirate smears. Based on the above findings, a diagnosis of blastic phase of CML with monocytosis with microfilaria of W.bancrofti. Hence this was an unusual case of CML blastic phase which was associated with filariasis. Moreover, inspite of having filariasis and CML, patient lacked eosinophilia and instead showed monocytosis, which is hitherto unreported.

Solitary bone plasmacytoma: An interesting case report with unusual clinico-cytological features.

Solitary bone plasmacytoma (SBP) is a rare entity characterized by localized proliferation of monoclonal plasma cells primarily occurring in the axial skeleton without systemic involvement. Involvement of the distal extremity is unusual. In the absence of typical clinical presentation, diagnosis may not be suspected clinico-radiologically; hence, fine-needle aspiration cytology may help in early and definitive diagnosis, hastening meticulous diagnostic workup and appropriate management of these patients. Intracytoplasmic crystalline inclusions (CI) have been reported in multiple myeloma and lymphoproliferative disorders. The present case highlights unusual clinico-cytological features of SBP with primary involvement of humerus, progression to tibia, and presence of extracellular and intracytoplasmic CI in plasma cells, a morphologic finding not reported in SBP earlier.

Paediatric idiopathic myelofibrosis.

Pediatric myelofibrosis is a rare disorder. It is usually secondary to other diseases. Rarely, when no underlying cause is found, it is termed idiopathic. We present here, a rare case of idiopathic myelofibrosis in a 10 year old male child. Bone marrow aspirate was dilute. Bone biopsy showed marrow fibrosis, with grade 2-3 reticulin fibres, with no evidence of granuloma, parasite or infilterative disorder. Acid fast bacillus stain was negative. Iliac lymph node biopsy showed reactive sinus histiocytosis with extramedullary hematopoeisis. Thus, diagnosis of pediatric idiopathic primary myelofibrosis was made. Idiopathic pediatric myelofibrosis should be suspected in a child with progressive pallor, hepatosplenomegaly and dry tap on bone marrow aspiration and marrow fibrosis on bone biopsy, after exclusion of secondary causes.