Ultrastructural features of basophil and mast cell granulopoiesis in blastic phase Philadelphia chromosome-positive leukemia.

Ultrastructural and ultracytochemical studies were performed on blood and bone marrow specimens from 18 patients with Philadelphia chromosome-positive blastic leukemia; 7 patients were in blast transformation following a typical history of chronic myelogenous leukemia and 11 patients presented with "acute leukemia." The patients were divided into 2 morphologic groups on the basis of light microscopic and cytochemical observations. In group I, which consisted of 11 patients, the proliferating cells were "lymphoid" in appearance and demonstrated many cytochemical, biochemical, and immunologic features similar to those of the lymphoblasts of non-T, non-B acute lymphoblastic leukemia. In group II, which consisted of 7 patients, the proliferating cells were myeloid in appearance. On the basis of ultrastructural observations, the 11 group I patients were divided into 2 subgroups, A and B. Subgroup IA, consisting of 5 patients, was characterized by blasts that demonstrated no differentiating features. In subgroup IB, consisting of 6 patients, 20-30% of the leukemic cells contained inclusions that resembled leukemic mast cell or basophil granules. The leukemic cells in the 7 group II patients manifested myeloid characteristics by light microscopy and prominent basophil and mast cell granulopoiesis by electron microscopy. Abnormalities of other myeloid cell lines were also observed in both the lymphoid and myeloid groups of patients.

Polymorphic diffuse B-cell hyperplasias and lymphomas in renal transplant recipients.

The lymphoproliferative processes that developed in five renal transplant recipients were studied in an attempt to characterize and classify them morphologically. Nine surgical specimens, hematological material on all patients, and autopsy specimens from three patients were available. Studies performed included: conventional histopathology; evaluation of cell markers (immunoglobulins and sheep erythrocyte, complement, and Fc receptors) and cytoplasmic immunoglobulins (peroxidase-antiperoxidase technique); ultrastructural examination; and karyotype analysis. The lymphoid lesions in our patients shared marked cytological polymorphism (small and large cells, of both follicular center and "medullary" type) and polyclonal B-cell features, which indicated a common reactive nonneoplastic origin. However, other features, such as morphological atypia of the immunoblasts, extensive necrosis, chromosomal aberrations, and an incipient monoclonal component suggested the development of lymphoma in some of these lesions. In contradistinction, the abundance of typical immunoblasts was a feature that seemed to correlate with the clinical activity of the disease rather than with the biological malignancy. The multiplicity of B-cell types and the presence of a follicular center cell component with diffuse distribution, as well as the extensive necrosis in the malignant forms, seem to differentiate morphologically the lymphoproliferative processes arising in transplant recipients from both the hyperplasias and the lymphomas developing in immunologically normal hosts. For the former, we propose the terms of "polymorphic diffuse B-cell hyperplasias" and "polymorphic B-cell lymphomas."

Chromosomal abnormalities in acute lymphoblastic leukemia.

Chromosome abnormalities in acute lymphoblastic leukemia (ALL) and their possible clinical significance are briefly reviewed based upon the literature and 60 cases studied at the University of Minnesota. Almost all cases of ALL appear to demonstrate clonal abnormalities; the major abnormal clone is usually hyperdiploid or pseudodiploid. Among cases of non-T, non-B ALL, at least four translocations appear to be present with an increased frequency: t(9;22); t(4;11); t(11;14); and t(1;3). Patients with these translocations appear to have unique clinical and laboratory findings. Although the presence of abnormal clones does not seem to influence remission duration, the nature of the abnormality does. Patients whose leukemias demonstrate predominantly a pseudodiploid abnormal clone or a translocation have significantly shorter first remissions. Most importantly, among patients with non-T, non-B ALL, the presence or absence of translocations may separate poor responders from good responders.

Glucocorticoid receptors and in vitro responses to glucocorticoid in acute nonlymphocytic leukemia.

Early clinical studies in which glucocorticoids were used alone in the treatment of acute nonlymphocytic leukemia (ANLL) reported a wide range of responses from remission in some patients to dramatic aggravation of the disease in others. In the hopes of identifying those patients likely to derive therapeutic benefit from glucocorticoids, we have studied glucocorticoid receptors and in vitro responses to glucocorticoids in 36 previously untreated adults with ANLL. The leukemic blasts of all patients contained glucocorticoid receptors (range, 4,300 to 28,400 total receptor sites per cell; median, 8,800). These receptors were similar in all respects studied to those from a variety of other normal and malignant tissues. There was little difference between receptor levels among the various French-American-British categories. In vitro responses to glucocorticoid were observed in leukemic blasts of 26 of 28 cases studied. These responses varied from near complete cell killing to stimulation of proliferation. Since the cells of patients with ANLL have about the same number of receptors as do cells from patients with acute lymphoblastic leukemia and these receptors are capable of mediating physiological responses in vitro, it is unlikely that qualitative or quantitative receptor defects underlie the relative resistance to glucocorticoid therapy of ALL compared to acute lymphoblastic leukemia. However, the broad range of in vitro responses and receptor levels suggests that these studies might be useful in identifying those patients with ANLL likely to derive benefit from steroid therapy.

Use of monoclonal antibodies, morphology, and cytochemistry to probe the cellular heterogeneity of acute leukemia and lymphoma.

A combined immunological, morphological, and cytochemical approach to the study of malignant cells in patients with acute leukemia and lymphoma is presented. Newly produced monoclonal antibodies that bind to antigens of human mononuclear cells (TA-1), or B-lymphocytes (BA-1) were used to study malignant cells from patients with acute lymphoblastic leukemia (ALL). acute myelocytic leukemia, acute myelomonocytic leukemia, and chronic lymphocytic leukemia. Results in lymphoid leukemia-lymphoma patients were compared with other immunological markers and indicate that the major groups of ALL and childhood non-Hodgkin's lymphoma are T-ALL, pre-T-ALL, pre-B-ALL, B-ALL, and non-T, non-B-ALL. In addition, each major group had multiple phenotypes when analyzed with seven immunological markers including the erythrocyte rosette receptor, surface immunoglobulin, cytoplasmic immunoglobulin M, the early lymphocyte-acute lymphoblastic leukemia antigen, monoclonal antibody TA-1, monoclonal antibody BA-1, and a monoclonal antibody against HLA-DR. While immunological heterogeneity was demonstrable within each group, distinct biological behavior was observed, with T-ALL and B-ALL generally presenting as "lymphomas" and the others presenting as "leukemias." Morphological analysis using the French-American-British classification provided independent information in the definition of groups with differing clinical behavior. Cytochemical analyses demonstrated focal paranuclear staining of leukemia cells with acid phosphatase in 73% of T-ALLs and 6% of non-T, non-B-ALLs.

Secondary acute myeloid leukemia in children with acute lymphoblastic leukemia treated with etoposide.

PURPOSE: To describe the occurrence of secondary acute myeloid leukemia (AML) in children with acute lymphoblastic leukemia (ALL) treated with etoposide (VP-16). PATIENTS AND METHODS: Two hundred five consecutive children with early B-lineage ALL were treated according to the Dallas/Fort Worth (DFW) protocol between January 1986 and July 1, 1991. Therapy included a four-drug induction followed by consolidation and continuation phases of nightly oral mercaptopurine (6-MP) and repetitive courses of divided-dose oral methotrexate (dMTX) and asparaginase (L-asp). Three doses of VP-16 and cytarabine (Ara-C) were given during consolidation and later, during continuation, two doses were given 3 to 4 days apart, every 9 weeks. Intrathecal (IT) chemotherapy was given throughout the treatment period. RESULTS: Two hundred three of the 205 patients entered remission. Only eight of these 203 children have had a bone marrow relapse (ALL). However, 10 other children have developed secondary AML 23 to 68 months following the diagnosis of ALL. Overall event-free survival (EFS) at 4 years is 79.3% +/- 5.1%, with a risk of secondary AML at 4 years of 5.9% +/- 3.2%. CONCLUSION: This experience provides strong evidence for a link between epipodophyllotoxin therapy and secondary AML since none of these children received alkylating agent therapy or irradiation. This serious complication raises concern as to the appropriate use of epipodophyllotoxins in the treatment of childhood ALL.

Acute promyelocytic leukemia. Management of the coagulopathy during daunorubicin-prednisone remission induction.

Seven adults with acute promyelocytic leukemia (APL) and disseminated intravascular coagulation were treated for remission induction with daunorubicin hydrochloride and prednisone. In all patients the coagulopathy was managed with continuous-infusion heparin sodium and vigorous transfusion with platelets, cryoprecipitate, and fresh frozen plasma. Five patients survived induction; they all achieved complete remission (CR). Median duration of CR was 27 + months; two patients presently survive in their initial CR at 28 and 48 months. Recognition of APL as a distinct type of acute leukemia and prompt initiation of treatment aimed at rapid cytoreduction and control of the coagulopathy has resulted in a prolonged disease-free survival for the majority of patients.

Trephine biopsy of the bone marrow in disseminated histoplasmosis.

Twenty-two patients had bone marrow aspirates for culture and marrow trephine biopsies for histologic examination during the evaluation of an illness eventually proved to be disseminated histoplasmosis. These procedures provided evidence of involvement of the bone marrow with Histoplasma capsulatum in 19 cases. Fungi were demonstrated in trephine biopsy sections in 15 of the patients, permitting a rapid specific diagnosis. Three patterns of bone marrow morphology were observed; each reflected a variation of macrophage proliferation. In two of the patterns, diffuse macrophage proliferation and loose aggregates of macrophages, typical 2 to 4 microns intracellular hisoplasma organisms were numerous and obvious in hematoxylin and eosin-stained sections, were infrequent and were often relatively large (6 to 12 microns). There were four patients from whom H. capsulatum was cultured when organisms could not be demonstrated in either hematoxylin and eosin- or silver-stained sections. The patients with diffuse proliferation of macrophages in the marrow comprised a distinct clinical group associated with immunosuppression, a fulminant course and a fatal outcome despite therapy. Patients in the other two morphologic groups responded well to therapy even though the immune responses on many were also suppressed. Bone marrow examination is an excellent diagnostic procedure in disseminated histoplasmosis. Trephine biopsies permit a rapid diagnosis in most cases and may be of prognostic significance.

Reversal of myelofibrosis in advanced breast cancer.

Reversal of myelofibrosis and splenomegaly is described in a 41 year old woman with metastatic breast cancer. After intensive chemotherapy and hormonal therapy, the tumor regressed, the splenomegaly receded, the hemogram showed no abnormalities, and the dense collagen and reticulin fibers in the marrow disappeared. The severe thrombocytopenia and leukoerythroblastosis noted before therapy were not obstacles to clinical management. In our report we document that myelofibrosis associated with breast cancer is not an ominous sign. Patients may benefit from an intensive, but well titrated, therapeutic program.

Chronic lymphoproliferative disorder with unusual clinical, morphologic, ultrastructural and membrane surface marker characteristics.

Four of 105 patients with chronic lymphocytic leukemia (CLL) manifested clinical, morphologic, ultrastructural and membrane surface marker characteristics that differed from those found in patients with typical CLL of demonstrated B-lymphocyte origin. These four patients presented with moderate increases in absolute lymphocyte counts, absolute neutropenia, polyclonal hypergammaglobulinemia and hepatosplenomegaly without lymphadenopathy. Two of them were unusually young, 19 and 25 years old, at the time of diagnosis. The proliferating lymphocytes carried receptors for sheep erythrocytes, a T-lymphocyte marker. In the three patients tested, the lymphocytes also carried Fc receptors. Ultrastructurally the lymphocytes contained cytoplasmic inclusion bodies consisting of parallel tubular arrays. The parallel tubular arrays corresponded to prominent cytoplasmic azurophilic granules on light microscopy. Parallel tubular arrays were found in less than 1 per cent of the lymphocytes in eight patients with typical B-lymphocyte CLL. The process in these four patients may be a distinctive chronic lymphoproliferative disorder originating in T lymphocytes with Fc receptors found in small numbers in the blood of normal persons.

Malignant histiocytosis: A light- and electron-microscopic and histochemical study.

The light- and electron-microscopic features and histochemical characterization of three consecutive cases of malignant histiocytosis (MH) are reported. Each case demonstrated involvement of lymph nodes and bone marrow. In the lymph node, the characteristic destructive sinusoidal pattern of involvement by cytologically malignant cells was present. Phagocytosis by malignant cells was rare and most readily appreciated in the imprint preparations. The major problem in differential diagnosis related to defining the histiocytic nature of the malignant cells. This question was resolved by the demonstration of diffuse cytoplasmic staining with the nonspecific esterase and acid phosphatase reactions as well as the ultrastructural demonstration of histiocytes. Although benign, reactive histiocytes were positive, malignant histiocytes did not stain for lysozyme by an immunoperoxidase technique. In contrast to the uniform appearance of these cases, many reports of MH in the past have consisted of heterogeneous cases with variable histologic appearances from a proliferation of predominantly mature histiocytes with marked phagocytosis to cytologically malignant cells with little apparent functional activity. This variation in histologic appearance is due in part to inclusion of cases of reactive histiocytic proliferations, including the recently described virus-associated hemophagocytic syndrome.

Systemic mastocytosis. Extracutaneous manifestations.

The clinical, radiologic, ultrastructural, and histopathologic findings in 14 patients with systemic mastocytosis were evaluated. Seven patients had evidence of urticaria pigmentosa (UP) and seven patients presented with no recognizable cutaneous lesions. There were no major clinical differences between patients with or without UP except for splenomegaly, which was present in one/seven patients with UP and five/seven patients without UP and the median age, 44 in patients with UP, and 75 in patients without UP. Bone marrow involvement was present in 13/13 specimens studied. Involvement was both focal and diffuse. The focal involvement occurred frequently in a perivascular and paratrabecular location. The diffuse involvement resembled myelofibrosis. Involved lymph nodes exhibited prominent sinusoidal and paracortical infiltration by mast cells. Splenic involvement was characterized by fibrosis occurring both focally and diffusely. The focal splenic involvement was perivascular and involved both the red and white pulp in a nonpreferential manner. Liver specimens showed prominent portal fibrosis. The morphology of the mast cells in the different lesions varied considerably; some were typical, others were spindle-shaped, and some resembled histocytes. The mast cells reacted positively with toluidine blue and chloroacetate esterase. Six patients had radiologic changes: three were osteoblastic, two osteolytic, and one osteoblastic and osteolytic. Two patients developed a poorly differentiated lymphoreticular tumor and one a myeloproliferative disorder after the diagnosis of mastocytosis.

Unusual bone marrow manifestations of parvovirus B19 infection in immunocompromised patients.

Parvovirus B19 is responsible for a spectrum of disease in humans. The usual bone marrow findings in acute parvovirus infections are marked erythroid hypoplasia and occasional giant erythroblasts. Intranuclear inclusions in developing erythroid precursors are rarely described in children or adults with parvovirus infection, although abundant intranuclear inclusions are commonly observed in the placenta and other tissues in infected fetuses. In this study, 8 patients are reported in whom the first evidence of parvovirus infection was the recognition of numerous intranuclear inclusions in erythroid precursors on bone marrow biopsy sections. Six of the 8 patients had documented immunodeficiencies; 4 had acquired immune deficiency syndrome (AIDS), and 2 were on chemotherapy. Five of 7 patients were negative for immunoglobulin G (IgG) antiparvovirus antibodies, including all 4 with AIDS. Unlike the typical pattern in parvovirus infection, the bone marrow was hypercellular in most of the patients, and erythroid precursors were usually increased with the entire spectrum of normoblast maturation represented; abundant intranuclear inclusions were observed similar to the finding in fetuses. The inclusions were variably eosinophilic and compressed the chromatin against the nuclear membrane. In situ hybridization showed parvovirus B19 DNA in numerous erythroid precursors in all cases. The findings of erythroid maturation and abundant viral inclusions in these immunocompromised patients is consistent with the hypothesis that failure to produce effective IgG parvovirus neutralizing antibodies may lead to persistent infection through viral tolerance that allows erythroid development of infected cells past the pronormoblast stage. Identification of parvovirus inclusions in marrow biopsies and subsequent confirmation of infection by in situ hybridization can be important in the assessment of anemia in immunodeficient patients because serological studies for parvovirus B19 are frequently negative.

New technology in laboratory medicine. A call for pathologists to lead the march.

Several new technologies are impacting the practice of pathology. Appropriate clinical uses must be defined and standards established. It is vitally important that pathologists play the leadership role in incorporating new diagnostic techniques in the clinical laboratory. To do so may require new knowledge and skills. Pathology associations must support the needs of their members by providing avenues for education and training in new technologies applicable to pathology practice.

Oxalosis. An unusual cause of myelophthisis in childhood.

In a child with renal failure and oliguria due to hyperoxaluria myelophthisis developed as a result of extensive bone-marrow replacement with calcium oxalate crystals and an accompanying fibrous proliferations. The histopathology associated with this metabolic disorder was demonstrated in posterior iliac crest bone-marrow trephine biopsies, renal biopsies, and nephrectomy specimens. Crystals were demonstrated in biopsy specimens of transplanted kidneys within six weeks following renal transplantation.

Reed-Sternberg-like cells in nodular lymphoma involving the bone marrow.

McKenna, Robert W., and Brunning, Richard D. Reed-Sternberg-like cells in nodular lymphoma involving the bone marrow. Am JClin Pathol 63: 779-785, 1975. Two patients with cells indistinguishable from Reed-Sternberg cells in bone marrow lesions of nodular poorly differentiated lymphocytic lymphoma are described. Both patients had lymph node biopsies showing nodular lymphoma. Bone marrow and blood involvement with the lymphoma was demonstrated at the time of initial diagnosis. Reed-Sternberg-like cells were not demonstrated in either case until later in the course of the disease, after the patients had been treated with numerous chemotherapeutic agents. Other similarities of bone marrow involvement with nodular lymphoma to Hodgkin's disease of the bone marrow are noted. The origin of the Reed-Sternberg-like cells in nodular lymphoma is not clear, but they could result from morphologicalteration of lymphoma cells by chemotherapy. The finding of Reed-Sternberg cells in bone marrow lesions should be interpreted with caution unless diagnostic biopsy material from other sites is available for study. (Key words: Bone marrow lymphoma' nodular lymphoma; Reed-Sternberg cells).

Large cell lymphoma transformation of chronic lymphocytic leukemia/small lymphocytic lymphoma. A flow cytometric analysis of seven cases.

We studied 7 cases of large cell transformation of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) immunophenotyped by multiparameter flow cytometry. The 6 women and 1 man ranged in age from 45 to 91 years. All had previous or concurrent evidence of CLL/SLL. Morphologic features and sites of involvement of the diffuse large B-cell lymphoma (DLBCL) were heterogeneous; 2 cases had paraimmunoblastic morphologic features. Six DLBCLs had an immunophenotype consistent with CLL: CD19+, CD5+, CD23+, and FMC7 negative (3 cases) or very dim (2 cases); 1 case was not studied for FMC7. CD20 was dim in 3 of these, moderate to bright in 2, and variable in 1. Surface immunoglobulin was dim in 2 cases and moderate or bright in 4. Five of 6 expressed CD38. Comparison with the immunophenotypes of the previous or coexistent CLL/SLL (4 of 6 cases) revealed minor modulations in antigen expression but no major alterations. The seventh DLBCL lacked CD5 expression, but otherwise had immunophenotypic features similar to CLL. These findings indicate that DLBCL arising in CLL/SLL tends to retain a CLL immunophenotype, in contrast with de novo CD5+ large cell lymphomas that uncommonly express such a phenotype.

Clinicopathologic analysis of CD10+ and CD10- diffuse large B-cell lymphoma. Identification of a high-risk subset with coexpression of CD10 and bcl-2.

We analyzed 53 cases of diffuse large B-cell lymphoma (DLBCL) to determine whether expression of CD10 is a relevant biologic parameter. Tumor morphologic features were assessed semiquantitatively. Bcl-2 protein expression was studied by immunohistochemical analysis. The presence or absence of CD10 by flow cytometry was correlated with clinical and pathologic characteristics. CD10+ (23 cases) and CD10- (30 cases) DLBCLs were indistinguishable based on age, sex, extranodal presentation, B symptoms, clinical stage, morphologic features, or bcl-2 expression. However, cases with a CD10+ phenotype showed a significantly lower rate of complete remission. Cases expressing bcl-2 showed trends toward a lower rate of complete remission and poorer overall survival. Examination of CD10 and bcl-2 interaction revealed that the prognostic effects for both of these antigens were due to a subset of CD10+ bcl-2-positive cases. Compared with cases expressing one or neither of these markers, patients with dual-positive tumors had a poorer complete response rate to initial therapy and strikingly worse overall survival. While CD10+ and CD10- DLBCLs are similar with regard to a variety of clinical and pathologic features, CD10 and bcl-2 coexpressing tumors are an extremely high-risk subset based on response to therapy and overall survival.

Bone marrow aspiration and trephine biopsy. An approach to a thorough study.

Recent advances in the treatment of hematologic malignancies have been paralleled by renewed interest on the part of pathologists and hematologists in methods of obtaining and preparing bone marrow for diagnostic studies. A thorough bone marrow morphologic study involves examination of peripheral blood smears, direct, particle, and buffy coat bone marrow smears, trephine biopsy imprints, particle and trephine biopsy sections, and marrow volumetric data. The information obtained from the study of these various specimens is complementary. Frequently it is a combination of clues gathered from examination of several different preparations that leads to a correct diagnosis. Utilization of biopsy material by the methods described provides complete, accurate and reproducible information and minimizes the necessity for repeating a biopsy for morphologic diagnosis or ancillary studies.

Bone marrow manifestations of peripheral T-cell lymphoma. A study of 30 cases.

Morphologic and clinical features of 30 patients with peripheral T-cell lymphoma (PTCL) were studied with particular attention to bone marrow and blood manifestations. Twenty-four (80%) patients had marrow involvement with lymphoma in trephine biopsies at initial diagnosis; two other patients subsequently developed marrow involvement. The bone marrow lesions were diffuse in 58% of the cases and focal, nonparatrabecular in 42%. A morphologic spectrum of lymphoma cells was seen with cases classified into small cell, mixed cell, and large cell/immunoblastic lymphoma. The bone marrow lesions were characterized by a heteromorphous population of lymphocytes, prominent vascularity with endothelial cell proliferation, reticulin fibrosis, and a polycellular infiltrate composed of plasma cells, eosinophils, and histiocytes. The histopathologic features in bone marrow biopsies were not pathognomonic for PTCL; the differential diagnosis may include non-Hodgkin's lymphomas of B-cell type, polymorphous reactive lymphoid lesions, including those from patients with acquired immune deficiency syndrome (AIDS), angioimmunoblastic lymphadenopathy, Hodgkin's disease, and systemic mastocytosis. The patients ranged in age from 13 to 81 years (median, 61 years) and generally presented with constitutional symptoms, lymphadenopathy, and hepatosplenomegaly. Abnormalities in one or more hematologic parameters were common and, in general, related to the degree of bone marrow involvement. Hypocalcemia was found in 40% of the patients studied and hypercalcemia in 4%. The median survival for PTCL patients was 11 months. Patients with small cell lymphoma, large cell/immunoblastic lymphoma, and marked eosinophilia had the shortest median survivals.