Bone marrow morphology during induction phase of therapy for acute myeloid leukemia (AML).

Sequential bone marrow aspirates and sections from patients with acute myeloid leukemia (AML) were examined to determine if a correlation exists between bone marrow morphology during induction phase of therapy and outcome. Of 95 patients of AML diagnosed between July 1987 and December 1991, 53 uniformly treated patients (induction therapy with cytosine arabinoside and daunorubicin) had sequential bone marrow examinations performed in the 2- to 5-week period following initiation of induction therapy. Four morphologic patterns were recognized in these 53 patients: Group I (22 patients)--hypocellularity or normal regeneration (> or = 15% cellularity and < 5% blasts) on the initial 2-week marrow followed by marrows showing normal regeneration; Group II (10 patients)--hypocellularity followed by "reactive myeloblastosis" (> or = 15% cellularity, 5% to 34% blasts, with promyelocytes = or > blasts); Group III (12 patients)--residual blasts (> or = 5% blasts with blasts >> promyelocytes) in the initial posttherapy marrow; Group IV (9 patients)--atypical patterns not fitting any of the other categories. Complete remission was achieved in all 32 patients in Groups I and II without additional induction therapy, but was achieved eventually in only 10 of 21 patients in Groups III and IV combined (p < 0.005), 15 of whom received additional induction therapy. Remission duration and actuarial survival for each group were as follows: Group I: 344/596 days; Group II: 443 days/> 660 days; Group III and IV combined: 351/311 days (p = 0.017 for actuarial survival). Seven of 21 patients in Groups III and IV had unfavorable initial morphology (MO, hypoplastic AML and AML preceded by myelodysplasia) compared to only 3 of 32 patients in Groups I and II (p = 0.039). It was thus observed that "reactive myeloblastosis" with up to 34% blasts on the third or fourth week bone marrow following an initial hypocellular marrow does not require additional induction therapy to achieve durable remissions or favorable survival. Also, residual blasts that outnumber promyelocytes, and atypical patterns of regeneration correlate with lower remission induction rates, shortened survival, and unfavorable morphology on the initial diagnostic bone marrow.

Howell-Jolly body-like inclusions in the neutrophils of patients with acquired immunodeficiency syndrome.

The authors have observed discrete, densely basophilic inclusions in the peripheral blood neutrophils of 10 patients with acquired immunodeficiency syndrome (AIDS) and two additional patients without documented evidence of human immunodeficiency virus seropositivity. These inclusions were seen in 3 of 25 (12%) patients with AIDS in a retrospective review. Gram, periodic acid-Schiff, and Gomori methenamine silver stains failed to demonstrate staining of these bodies; however, the Feulgen reaction was positive. The inclusions may represent "apoptotic" nuclear fragments and thus may be similar to Howell-Jolly bodies of normoblasts in abnormal erythropoiesis. An association of these inclusions with nucleoside analogue antiviral therapy is indicated. These inclusions must be differentiated from intracytoplasmic infectious agents, Döhle bodies, and inclusions of inherited disorders.

Expression of CD24 (BA-1) predicts monocytic lineage in acute myeloid leukemia.

Fifty-seven cases of acute myeloid leukemia (AML), which had been subtyped by French-American-British morphologic and cytochemical criteria as myeloid (M1, M2) or monocytic (M4, M5), were retrieved from the files of the Division of Hematopathology, University of Iowa. Corresponding immunophenotyping data were reviewed with attention to the expression of CD14 (MY4) and CD24 (BA-1). Of 20 cases expressing CD24, 19 were M4 or M5, whereas all 14 cases expressing CD14 were of monocyte lineage. Therefore, CD14 was a highly specific (100%) but only moderately sensitive (58%) marker for distinguishing classes M1 or M2 from M4 or M5. By contrast and unexpectedly, CD24 was nearly as specific (97%), but more sensitive (79%) in marking M4 or M5 cells. This appears to be true even though CD24 is apparently not expressed on normal monocytes. When positive staining for either or both antibodies (CD24 or CD14) was considered indicative of a monocytic leukemia, the sensitivity of immunophenotyping in distinguishing M4/M5 from M1/M2 AML rose to 92%, while maintaining 97% specificity. The authors discuss a recent observation that may help explain the unexpected expression of CD24 in monocytic AML. They conclude that the usefulness of CD24 in identifying monocytic AML may exceed that of CD14, and that the use of CD24 and CD14 in combination improves the ability of flow cytometry to distinguish myeloid from monocytic acute leukemias.

Minimally differentiated acute leukemia.

We have studied 35 adult patients with morphologically undifferentiated peroxidase-negative acute leukemia that failed to meet the criteria for acute lymphoblastic leukemia and compared them to patients with FAB M1-M7 seen by the same physicians. The diagnosis of minimally differentiated acute leukemia (MD-AL) was associated with a higher incidence of prior hematologic disease, lower WBC, fewer blood blasts, lower marrow cellularity and a tendency towards older age. Of all patients treated with AML since January 1983, those with MD-AL were less likely to get a complete remission than those with other subtypes (35 vs 64%, p = 0.03). Treatment failure was usually due to resistant disease. Analysis of outcome as a function of drugs used during induction therapy showed an advantage for regimens containing vincristine and prednisone. The leukemic blast cells of nine patients were immunophenotyped for myeloid, lymphoid and megakaryoblast/platelet antigens. Although there were too few for a full statistical analysis as was applied to the larger group of 35 patients with MD-AL, these patients had a lower bone marrow cellularity as compared to FAB M1-M7 and a low remission rate. Eight of these were found to have positive myeloid markers and met the criteria for FAB M0. We conclude that patients with MD-AL form a distinct group with characteristic presenting features and a low response rate. Outcome data suggest that vincristine and prednisone should be included in experimental induction programs.

Congenital dyserythropoietic anemia type II diagnosed in a 69-year-old patient with iron overload.

Congenital dyserythropoietic anemia type II is a rare disorder that is often diagnosed in patients before age 20 years. Patients with this disorder, which is also called hereditary erythroblastic multinuclearity associated with a positive acidified serum lysis test, may have symptoms of iron overload. The purpose of this case report is to alert physicians to consider the diagnosis of congenital dyserythropoietic anemia type II in elderly patients who have anemia and iron overload.

Pesticides and other agricultural risk factors for non-Hodgkin's lymphoma among men in Iowa and Minnesota.

Data from an in-person interview study of 622 white men with newly diagnosed non-Hodgkin's lymphoma and 1245 population-based controls in Iowa and Minnesota were used to measure the risk associated with farming occupation and specific agricultural exposures. Men who ever farmed were at slightly elevated risk of non-Hodgkin's lymphoma (odds ratio = 1.2, 95% confidence interval = 1.0-1.5) that was not linked to specific crops or particular animals. Elevated risks were found, with odds ratio generally 1.5-fold or greater, for personal handling, mixing, or application of several pesticide groups and for individual insecticides, including carbaryl, chlordane, dichlorodiphenyltrichloroethane, diazinon, dichlorvos, lindane, malathion, nicotine, and toxaphene. Associations were generally stronger for first use prior to 1965 than more recently, and when protective clothing or equipment was not used. Small risks were associated with the use of the phenoxyacetic acid herbicide 2,4-dichlorophenoxyacetic acid, but the risks did not increase with latency or failure to use protective equipment. Exposure to numerous pesticides poses problems of interpreting risk associated with a particular chemical, and multiple comparisons increase the chances of false-positive findings. In contrast, nondifferential exposure misclassification due to inaccurate recall can bias risk estimates toward the null and mask positive associations. In the face of these methodological and statistical issues, the consistency of several findings, both within this study and with observations of others, suggests an important role for several insecticides in the etiology of non-Hodgkin's lymphoma among farmers.

Clonal immunoglobulin gene rearrangement in the infarcted lymph node syndrome.

The authors report a case of complete lymph node infarction in which a specific etiology could not be determined by morphologic or immunophenotypic studies; however, clonal rearrangement of the immunoglobulin gene was demonstrated by Southern blot hybridization of DNA extracted from the necrotic tissue. A subsequent lymph node biopsy later was diagnosed as malignant lymphoma, using morphologic, immunophenotypic and genotypic criteria. Identical clonally rearranged bands were present in DNA from both the infarcted nodal and the subsequent tissue biopsies. In the setting of lymph node necrosis, gene rearrangement studies may provide diagnostic information concerning clonality, even if morphologic and immunophenotypic studies are indeterminate for a lymphoproliferative process.

Clonal immunoglobulin gene rearrangement in nodular lymphoid hyperplasia of the gastrointestinal tract associated with common variable immunodeficiency.

The authors report a case of common variable immunodeficiency associated with nodular lymphoid hyperplasia of the gastrointestinal tract in which a clonal population of lymphoid cells was detected by immunophenotypic and genotypic studies on tissue obtained by colonoscopic biopsy. The patient has been followed up for more than 50 months without clinical, radiographic, or pathologic evidence of lymphoma. The significance of clonal rearrangement in the setting of immunodeficiency and the role of genotypic studies in defining lymphoid malignancy are discussed.

Immunophenotypic and genotypic characterization of primary non-Hodgkin's lymphoma of the gastrointestinal tract.

Antigen receptor gene rearrangement studies have been applied to gastrointestinal (GI) lymphoid proliferations in only a limited number of cases, and their use and contribution to the diagnosis and characterization of GI lymphomas is unknown. We retrospectively studied 17 cases of primary GI lymphoma using fresh/frozen tissue with a combination of immunophenotypic and genotypic techniques. The vast majority of the neoplasms were B-cell lymphomas (88%) with rare T-cell tumors. The most common B-cell immunophenotype was IgM-kappa (40%), while five of the B-cell lymphomas (33%) lacked surface light chain immunoglobulin. Immunophenotypic evidence of histiocytic differentiation was not identified. Clonality was confirmed in 59% (10/17) of the neoplasms by immunophenotyping and 88% (15/17) by antigen receptor gene rearrangement studies. All of the 15 B-cell lymphomas (100%) demonstrated clonally rearranged immunoglobulin gene rearrangement. The two lymphomas with T-cell immunophenotypes did not demonstrate T-cell receptor beta-chain gene rearrangement. Antigen receptor gene rearrangement data can be useful and may even be necessary in certain cases for the proper classification and/or diagnosis of GI lymphoid proliferations.

Kappa immunoglobulin light chain gene rearrangement in a T-lineage chronic lymphocytic leukemia.

Until recently, only B-lineage lymphoid cells were observed to rearrange kappa immunoglobulin light chain genes. The authors examine peripheral blood mononuclear cells from a patient with chronic lymphocytic leukemia. More than 90% of these cells bound T-lymphocyte specific antibodies, failed to bind B-lymphocyte specific antibodies, had rearranged T-cell receptor beta-chain genes and had retained immunoglobulin heavy chain genes in the germline configuration. Despite these T-lineage markers, the majority of these cells had rearranged kappa immunoglobulin light chain genes. This provides the first conclusive evidence for rearranged kappa genes in malignant T-lineage cells and warns that gene rearrangement studies alone cannot indicate tumor cell lineage. To detect T-lineage cells that rearrange immunoglobulin genes, multiple immunophenotypic and genotypic parameters must be evaluated. These cells may provide important models to study how normal and malignant cells rearrange lymphocyte receptor genes.

The diagnostic utility of immunophenotyping and immunogenotyping in the pathologic evaluation of lymphoid proliferations.

One hundred eighty-two specimens of suspected lymphoma and lymphocytic leukemia were examined by morphology, immunophenotype, and immunogenotype (genotype) in order to answer the following questions: How often and in what situations does immunophenotyping help resolve a diagnostic problem that is not resolved by morphology? How frequently does genotyping help resolve a diagnostic problem that is not resolved by morphology and immunophenotyping? Of 182 cases for which fresh tissue was available, sixty-five cases were considered morphological diagnostic problems: There were 32 cases of neoplasia versus non-neoplastic proliferation, 16 cases of neoplasia with undifferentiated or ambiguous morphology, and 17 cases of lymphoma or lymphocytic leukemia with an uncertain subtype. Immunophenotyping helped to resolve 33 of these 65 cases. Of the remaining 32 cases genotyping helped to resolve the diagnosis in 16. These results suggest that immunophenotyping may diagnose approximately 50% of those cases which present a morphological problem, and that genotyping is also helpful in a limited but significant number of problem cases.

Analysis of immunoglobulin and T-cell receptor gene rearrangement in cytologic specimens.

Recombinant DNA techniques to detect the rearrangement of genes encoding immunoglobulins and T-cell-antigen receptors have been used to identify clonality in lymphoid lesions. To determine the utility of such techniques in cytologic specimens, DNA was analyzed in 24 effusions and 6 fine needle aspirates. Immunophenotypic studies were also performed on the 19 specimens with suspected hematopoietic malignancies. Sufficient material for DNA analysis was present in 28 of the 30 specimens. Immunoglobulin or T-cell-receptor gene rearrangement was present in 13 specimens with atypical cytologic findings; DNA studies provided more information than did the immunologic studies in 3 cases. One T-cell malignancy showed T-cell receptor and heavy-chain gene rearrangement, and one B-cell malignancy showed immunoglobulin and T-cell receptor gene rearrangement. In all patients except one with no evidence of gene rearrangement, the morphologic and immunologic studies also favored a reactive process. Control specimens showed a germline configuration. This study demonstrated that DNA gene rearrangement studies are feasible on many cytologic specimens and may be useful in diagnostically difficult cases.

8;21 translocation in acute nonlymphocytic leukemia. Occurrence in M1 and M2 FAB subtypes.

Ten patients with acute nonlymphocytic leukemia (ANLL) and the 8;21 chromosome translocation were observed over an eight-year period. The mean age of the patients was 31, and nine achieved a complete remission. Six were classified as ANLL-M2, three as ANLL-M1, and one as borderline M1/M2. A missing sex chromosome was also observed in four of the ANLL-M2 patients but not in the three M1 patients. An increased number of dyspoietic myeloid cells and/or basophils was present in four patients in day 14 or 21 marrows after induction therapy, but this feature did not appear to adversely affect prognosis. Previous reports have stated that t(8;21) occurs almost exclusively in ANLL-M2. However, by revised French-American-British criteria for classification of ANLL, the M1 subtype may also be observed with significant frequency.

Epstein-Barr virus-related lymphoproliferative disorders following bone marrow transplantation: an immunologic and genotypic analysis.

Four patients from 1.5 to 18 yr of age who had received partially matched T-cell-depleted bone marrow transplants for acute leukemia succumbed to a widespread lymphoproliferative disorder (LPD) at 56 to 147 days after transplant. Premortem diagnosis of LPD was suggested in two because plasmacytoid cells were observed in the blood and bone marrow, and in the cerebrospinal fluid of one of these patients. Serum clonal immunoglobulins (Igs) were also demonstrated in these two patients premortem, while the other two had clonal Igs in serum obtained at autopsy. Autopsies revealed a plasmacytoid infiltrate or immunoblastic lymphoma involving lymph nodes, spleen, liver, lungs, gastrointestinal tract, and kidneys. Immunoglobulin gene rearrangement studies performed in three revealed B-cell clonality. Both immunohistochemical and DNA gene rearrangement studies were useful in differentiating the LPD from the pretransplant leukemia. Epstein-Barr virus (EBV) genome was found in the tissues of the three patients studied. The diagnosis of EBV-induced LPD must be considered in bone marrow transplant patients who deteriorate and who exhibit serum clonal Igs or prominent plasmacytoid cells in laboratory specimens.

Adult acute lymphoblastic leukemia: results of the Iowa HOP-L protocol.

Fifty-nine consecutive previously untreated adult patients with acute lymphoblastic leukemia (ALL) were entered onto a prospective single-arm trial of doxorubicin, vincristine, prednisone, and asparaginase (HOP-L) induction therapy followed by CNS prophylaxis and 3 years of maintenance therapy. Consolidation therapy was not administered. The study population included a large number of older (greater than 50 years) patients. Seventy-five percent of patients achieved complete remission. With a median follow-up of 6 years, the median duration of complete remission is greater than 4 years, with 53% of patients expected to remain in remission at both 3 and 5 years. Overall, median survival duration is 27.9 months, with 45% and 35% of all patients expected to survive 3 and 5 years, respectively. Multivariate analysis identified patients with T-cell disease and mediastinal masses (P less than .001) and those with low values of lactic dehydrogenase (LDH) (P = .057) as being at greatest risk of relapse. Therapy was well tolerated by patients under age 35, but older patients suffered appreciable mortality. We conclude that this treatment program is effective therapy for adult ALL, yielding a large proportion of durable remissions despite the exclusion of consolidation therapy.

Hair dye use and risk of leukemia and lymphoma.

Data from a population-based case-control study of incident leukemia and non-Hodgkin's lymphoma among adult men in Iowa and Minnesota were used to evaluate risk associated with hair dye use. The relative risk for ever using hair dyes was 1.8 (95% confidence interval [CI] = 1.1-2.7) among leukemia patients, and 2.0 (CI = 1.3-3.0) among cases with non-Hodgkin's lymphoma. There was a suggestion of increased risk with extent of hair dye use. Given the widespread use of hair coloring products, these observations deserve more detailed evaluation in populations where the exposure is relatively common.

Nonconcurrence in abstracted diagnoses of non-Hodgkin's lymphoma.

The availability of two independent sets of abstracted diagnoses on 289 cases of non-Hodgkin's lymphoma (NHL), one from the Iowa Surveillance, Epidemiology, and End Results (SEER) Program and the other from an epidemiologic study in Iowa of factors affecting rural males (FARM), allowed us to determine the disagreement between abstracted diagnoses. For both sets the reported diagnosis was translated to International Classification of Disease for Oncology terminology and then to the Working Formulation (WF). Comparison of the WF diagnoses between the FARM study and the SEER Program showed disagreement in 68 of 290 cases (23.4%). Apparent causes of disagreement were as follows: coding errors-9 cases, unconventional or ambiguous terminology on reports resulting in different interpretation of the NHL subtype--30 cases, differences in coding rules for the FARM study and SEER Program--9 cases, acquisition of different reports with different diagnoses on the same case by the FARM study and SEER Program--20 cases. Several corrective measures that might successfully decrease the incidence of disagreement include: education of pathologists in the use of conventional terminology, and use of the category "unclassifiable" when abstracting reports with unconventional or ambiguous terminology. This 23.4% disagreement rate in the abstracting method adds to the known problem of nonconcurrence in the pathologic diagnosis of subtypes of NHL.

Prediction of bone marrow iron findings from tests performed on peripheral blood.

After evaluating multiple tests, the authors have devised a scheme to predict bone marrow iron findings from tests performed on peripheral blood. They examined bone marrows from 97 consecutive patients with anemia who were divided into five marrow morphologic groups: (1) iron deficiency; (2) anemia of chronic disease; (3) abnormal sideroblasts; (4) ring sideroblasts; and (5) other. Tests of peripheral blood included hemoglobin, hematocrit, red blood cell count and red blood cell indices, reticulocyte count, sedimentation rate or zetacrit, ferritin, iron, iron binding capacity, free erythrocyte protoporphyrin, and tests of hepatic and renal function. Cluster analysis, multidimensional scaling, and logistic discriminant analysis were used to derive a graph of serum ferritin with the sedimentation rate, allowing accurate confirmation or exclusion of iron deficiency in most patients. Percent saturation of serum transferrin and serum ferritin allowed identification of only 50 percent of patients with abnormal or ring sideroblasts while excluding 100 percent of patients without abnormal or ring sideroblasts. In three years of follow-up, two of 19 patients with abnormal or ring sideroblast have developed the dysmyelopoietic syndrome or ANLL, respectively. With the aid of the two parameter graphs described, the authors believe the differential diagnosis of the hypoproliferative anemias relating to iron metabolism can frequently be made without examination of the bone marrow.

Long-term relapse-free survival in adult acute lymphoblastic leukemia.

An intensive treatment program with curative intent was designed for adults with acute lymphoblastic leukemia (ALL). Forty-eight consecutive patients were treated with this protocol and 39 (81%) obtained a complete remission. Although the complete remission rate was high for patients with both null- and T-cell disease, those with null-cell leukemia had a significantly greater median duration of remission (greater than 306 weeks) than patients with T-cell disease (62 weeks). The median survival by life-table analysis for the 48 patients is projected to be greater than 310 weeks, and five patients have finished the 3-year treatment program and have been off therapy for 1-3 years without recurrence of disease. Classification of adult ALL by immune marker status is an important and easily done pretherapy maneuver that identifies subsets of patients with a significantly different prognosis when treated with the protocol described in this study. Those patients for whom leukemic cells had T-cell characteristics had a short median duration of remission. Most importantly, this treatment protocol identifies by therapeutic response a subset of adult patients with ALL whose leukemic blasts are characterized by the absence of immunological markers and who appear, in substantial proportion, to be potentially curable.