Long-lasting fever of unknown origin preceding the diagnosis of intravascular lymphomatosis: a further case stimulates some remarks

Neurological and skin involvements usually dominate the clinical presentation of intravascular lymphomatosis (IL), while fever is the most frequent general sign. However, an onset only characterized by fever of unknown origin (FUO) has been rarely reported. We would like to describe a further case of IL, which presented a long-lasting FUO before the diagnosis. At admission, physical examination detected hepatosplenomegaly without lymph nodes enlargement or dermatological or neurological abnormalities. Significant laboratory data included severe anemia, leukopenia, thrombocytopenia, and increased serum LDH. Moreover, a chest CT evidenced bilateral multiple pulmonary infiltrates and pleural effusion. After the development of proteinuria, a diagnosis of large B-cell intravascular lymphoma was made with a renal biopsy 10 months after the onset of the clinical manifestations. So far, more than 100 cases of IL have been reported and the diagnosis often turned out to be difficult, as clinical signs did not point to a lymphoproliferative disorder. This report confirms that FUO is not only frequently associated with IL but that it even marks the real onset of the disease. We are then tempted to conclude that undiagnosed fever is not so rare in IL and if we call it FUO, it is only because diagnosis is necessarily elusive and hence time-consuming.

[Testicular malignant lymphoma: a case report]

We report a case of malignant lymphoma arising from the testicle in a patient who had been on chemotherapy for a long period after orchiectomy. A 54-year-old male presented with indolent swelling in the right scrotum. Diagnosed as having a testicular tumor by ultrasonography and MRI, he underwent orchiectomy. According to the histopathological diagnosis, the tumor was classified as non-Hodgkin's lymphoma, diffuse large cell type, B cell type. Diagnosis of Stage I eA was made by the Arr Arbor classification. Four courses of cycrophosphamide, adriamycin, vincristin and prednisolone (CHOP) therapy were administered. COP (CHOP minus adriamycin) therapy has been given every four months on an out-patient basis. At present, 28 months after the operation, no evident recurrence has been found.

Hematological neoplasms with first presentation as spinal cord compression syndromes: a 10-year retrospective series and review of the literature

CONTEXT

The epidural space is a well-known, albeit uncommon, location for lymphomatous involvement, estimated to occur in less than 3% of all systemic lymphomas. Initial presentation of the patient with disease in this site (i.e. primary spinal epidural lymphoma) has been considered to be "rare". When it has been reported, many studies have emphasized the occurrence of aggressive lymphomas with a poor prognosis.

DESIGN

A 10-year retrospective search of our files generated 7 patients who presented initially with back pain, incontinence and/or lower extremity weakness, and by neuroimaging studies were found to have masses causing spinal cord compression syndromes necessitating neurosurgical intervention.

RESULTS

The 7 patients included 4 males and 3 females with thoracic and lumbar epidural masses. Tumor types included high-grade non-Hodgkin lymphoma, B cell type (n = 4), indolent B cell lymphoma (n = 1), nodular sclerosing Hodgkin lymphoma (n = 1) and plasmacytoma (n = 1). Advanced disease (stage 4) was subsequently identified in all 7 patients. Despite this, survival varied greatly with therapy, from 3 weeks to almost 6 years, underscoring the need for correct classification of the lymphoma in order to optimize chemotherapeutic choices. The epidural space was the site of presentation of disease in 4% of all lymphomas diagnosed at our institution.

CONCLUSIONS

Combining all reports in the literature, epidural presentation of lymphoma is not rare. Epidural lymphomas are distinct from both primary central nervous system lymphomas and from primary dural lymphomas. A broad range of systemic hematological tumor types can present as epidural masses. A full work-up for lymphoma classification may only be possible from the tissues received at the time of the neurosurgical decompression or biopsy procedure.

Diagnosis of primary cutaneous B-cell lymphoma by immunohistochemical and in situ hybridization methods

A diagnosis of primary cutaneous B-cell lymphoma is mainly supported by identification of a monoclonal B-cell population in the skin. This identification is made either by immunohistochemistry techniques using monoclonal antibodies towards the lambda or kappa chains, or by PCR for the heavy chain of immunoglobulins. Immunohistochemistry has a low sensitivity in detecting monoclonality, whereas the PCR technique is sensitive, but does not permit the localization of tumour cells in the skin. The aim of this study was to determine whether a monoclonal population in the skin could be detected by in situ hybridization. Thirty-eight skin biopsies from patients with primary cutaneous B-cell lymphoma were studied. Monoclonality was observed in 24/38 (63%) biopsies using immunohistochemical methods and 32/38 (84%) when combining this with in situ hybridization. It is concluded that kappa or lambda chain in situ hybridization is an interesting complementary technique to detect monoclonal B cells, if the immunohistochemical technique is negative.

Development of consensus fluorogenically labeled probes of the immunoglobulin heavy-chain gene for detecting minimal residual disease in B-cell non-Hodgkin lymphomas

We have examined 72 patients with B-cell non-Hodgkin lymphoma (B-NHL) in order to search for consensus sequences of the immunoglobulin heavy chain (IgH) gene, and developed consensus fluorogenically labeled probes for use in an allele-specific oligonucleotide (ASO) real-time quantitative polymerase chain reaction (RQ-PCR) assay of minimal residual disease (MRD). We detected a clonal IgH variable region (VH) sequence in 51 (70.8%) of the 72 B-NHLs, the most frequent VH gene usages being VH3 and VH4 (45/51, 88.2%). It was possible to design three consensus fluorogenic probes for the VH3 gene and one for the VH4 gene avoiding these hypermutations. Our sequencing results suggested that consensus fluorogenic probes would be best based on the 5'-side of the framework region 3 (FR3) because the frequency of somatic hypermutations was significantly lower in the regions on which the probes were based than in the remaining parts of FR3 (P < 0.05). Nineteen (54.3%) of 35 B-NHLs with the VH3 gene and 5 (50%) of 10 with the VH4 gene had sequences identical to at least one of these probes. We found that probes containing one base substitution were still applicable for a MRD study, whereas those containing two or more were not. Therefore, our four probes were applicable for 37 (82.2%) of the 45 patients with VH3 or VH4. This limited number of probes makes a large-scale study of MRD in B-NHL more feasible.

[Erythema nodosum association with malignant lymphoma]

Erythema nodosum is the most frequent clinicopathological variant of the panniculitides. The disorder is a cutaneous reaction consisting of inflammatory nodular lesions, usually located on the lower extremities. It may be associated with a wide variety of diseases, infections, sarcoidosis, rheumatologic diseases, inflammatory bowel diseases, medications and malignancies. Relationship between erythema nodosum and malignant lymphoma is described in the article. A review of the literature suggest that the diagnosis of Hodgkin's and non-Hodgkin's disease should be considered in patients with unexplained erythema nodosum.

Evaluation of vitrectomy specimens and chorioretinal biopsies in the diagnosis of primary intraocular lymphoma in patients with Masquerade syndrome

PURPOSE

To correlate the histopathological diagnoses established by diagnostic vitrectomy and chorioretinal biopsy in patients with clinically suspected primary intraocular lymphoma (PIOL) or chronic idiopathic uveitis, and the clinical follow-up data.

METHODS

Eighty-four consecutive pars plana vitrectomy (PPV) specimens, three chorioretinal biopsies and two enucleated eyes taken from 80 patients were evaluated. All PPV specimens were unfixed; these were centrifuged, the "cytospins" being stained conventionally (May-Grünwald-Giemsa) and using immunocytology (CD79a, CD3, CD68, immunoglobulin (Ig) light chains). An extended immunohistochemical panel, as well as polymerase chain reaction (PCR) for rearrangements of the Ig heavy chain gene (IgH-PCR), were used to investigate the chorioretinal biopsies and the enucleated eyes. Diagnoses, made on the basis of morphology and immunophenotype, included "reactive cellular infiltrate", "malignant lymphoma", "suspicious of neoplastic disease", and "insufficient for diagnosis". The corresponding clinical data were collected and compared with the diagnosis.

RESULTS

The 80 patients consisted of 46 women and 34 men. The patients' age range varied from 21 to 100 years (mean age 62 years). Sixty-two (74%) of the 84 vitrectomy specimens were diagnosed as "reactive cellular infiltrate", 12 (14%) as definite "malignant lymphoma", 5 (6%) as "suspicious of neoplastic disease" and 5 (6%) specimens were considered "insufficient for diagnosis". An additional chorioretinal biopsy enabled an unequivocal diagnosis of PIOL to be reached in 3 patients. All PIOL were diffuse large cell B-cell lymphoma (DLBCL), with the immunophenotype CD79+, CD20+, BCL-2+, BCL-6+, MUM1+ and monotypical expression for IgM+. A monoclonal IgH-PCR amplification product was obtained in four vitrectomy specimens, two chorioretinal biopsies and one of the enucleated eyes. Comparison of the diagnoses with long-term follow-up clinical data resulted in concordance in 77 (96%) cases and discrepancies ("false-negative" diagnoses) in 3 patients (4%). The patients diagnosed with lymphoma were treated with either radiotherapy, chemotherapy or both. At final follow-up (mean 35 months), 5 patients (6%) had developed cerebral lymphomatous manifestation, and 7 (9%) had succumbed to their disease.

CONCLUSION

The diagnosis of PIOL is often extremely difficult, requiring sufficient rapidly transported good-quality material, and experienced interpretation. Although cytological examination of vitreal aspirates remains the gold standard in diagnosis, examination of chorioretinal biopsies increase the reliability of diagnosing or excluding a PIOL that involves the retina or choroid. Most PIOL are DLBCL with an immunophenotype suggesting a cellular origin from germinal centre cells.

Primary pancreatic lymphoma presenting as acute pancreatitis

Primary pancreatic lymphoma is a rare disease and usually presents with nonspecific symptoms like abdominal pain, weight loss, or jaundice. Here we report a case of primary pancreatic lymphoma presenting as acute pancreatitis.

Molecular diagnosis of primary mediastinal B cell lymphoma identifies a clinically favorable subgroup of diffuse large B cell lymphoma related to Hodgkin lymphoma

Using current diagnostic criteria, primary mediastinal B cell lymphoma (PMBL) cannot be distinguished from other types of diffuse large B cell lymphoma (DLBCL) reliably. We used gene expression profiling to develop a more precise molecular diagnosis of PMBL. PMBL patients were considerably younger than other DLBCL patients, and their lymphomas frequently involved other thoracic structures but not extrathoracic sites typical of other DLBCLs. PMBL patients had a relatively favorable clinical outcome, with a 5-yr survival rate of 64% compared with 46% for other DLBCL patients. Gene expression profiling strongly supported a relationship between PMBL and Hodgkin lymphoma: over one third of the genes that were more highly expressed in PMBL than in other DLBCLs were also characteristically expressed in Hodgkin lymphoma cells. PDL2, which encodes a regulator of T cell activation, was the gene that best discriminated PMBL from other DLBCLs and was also highly expressed in Hodgkin lymphoma cells. The genomic loci for PDL2 and several neighboring genes were amplified in over half of the PMBLs and in Hodgkin lymphoma cell lines. The molecular diagnosis of PMBL should significantly aid in the development of therapies tailored to this clinically and pathogenetically distinctive subgroup of DLBCL.

Discrimination of metastatic cervical lymph nodes with diffusion-weighted MR imaging in patients with head and neck cancer

BACKGROUND AND PURPOSE

Metastasis to the regional cervical lymph nodes may be associated with alterations in water diffusivity and microcirculation of the node. We tested whether diffusion-weighted MR imaging could discriminate metastatic nodes.

METHODS

Diffusion-weighted echo-planar and T1- and T2-weighted MR imaging sequences were performed on histologically proved metastatic cervical lymph nodes (25 nodes), benign lymphadenopathy (25 nodes), and nodal lymphomas (five nodes). The apparent diffusion coefficient (ADC) was calculated by using two b factors (500 and 1000 s/mm(2)).

RESULTS

The ADC was significantly greater in metastatic lymph nodes (0.410 +/- 0.105 x 10(-3) mm(2)/s, P <.01) than in benign lymphadenopathy (0.302 +/- 0.062 x 10(-3) mm(2)/s). Nodal lymphomas showed even lower levels of the ADC (0.223 +/- 0.056 x 10(-3) mm(2)/s). ADC criteria for metastatic nodes (>/= 0.400 x 10(-3) mm(2)/s) yielded a moderate negative predictive value (71%) and high positive predictive value (93%). Receiver operating characteristic analysis demonstrated that the criteria of abnormal signal intensity on T1- or T2-weighted images (A(z) = 0.8437 +/- 0.0230) and ADC (A(z) = 0.8440 +/- 0.0538) provided similar levels of diagnostic ability in differentiating metastatic nodes. The ADC from metastatic nodes from highly or moderately differentiated cancers (0.440 +/- 0.020 x 10(-3) mm(2)/s, P <.01) was significantly greater than that from poorly differentiated cancers (0.356 +/- 0.042 x 10(-3) mm(2)/s).

CONCLUSION

Diffusion-weighted imaging is useful in discriminating metastatic nodes.

Primary lacrimal sac B-cell immunoblastic lymphoma simulating an acute dacryocystitis

The case of a 72-year-old woman with diffuse large B-cell lymphoma of the lacrimal sac is reported. The patient was evaluated for the first time in our department for tearing of the right eye. One month later, a slightly aching mass appeared over the right lacrimal sac. An acute infectious etiology was suspected and antibiotic therapy was given. When she finally presented with a rapidly growing lesion, she underwent echography and computed tomography followed by incisional biopsy. Results of histopathologic and immunohistochemical evaluation showed a primary, diffuse, large B-cell non-Hodgkin lymphoma of the lacrimal sac. This case demonstrates how difficult the clinical diagnosis of tumors of the lacrimal sac may be in the early stages. The clinical signs, usually aspecific, may be misleading and the diagnosis delayed.

Etiology and therapy of Helicobacter pylori-associated gastric lymphomas

The WHO separates marginal zone B-cell lymphomas (MZBL) of nodal and extranodal type. Both arise from memory B cells of the marginal zone. Extranodal MZBL of the mucosa-associated lymphatic tissue (MALT) have characteristic features such as homing in epithelial tissue, lymphoepithelial destruction, and a very indolent clinical course. They arise in epithelial tissues normally devoid of lymphatic cells, where the lymphatic tissue was acquired after, for instance, a chronic infection. The best example here is infection of the stomach with Helicobacter pylori ( Hp). Besides the classical association with gastric MALT lymphomas, there have been reports in which an association between Hp and diffuse large B-cell lymphoma (DLBCL) has been observed as well. Consequently, cure of Hp infection resulted in remission induction not only in gastric MALT lymphomas, but also in some patients with very limited stages of DLBCL of the stomach. In addition to the association with Hp, progress has been made with regard to MALT lymphoma biology. Translocation t(1;14) involving the Bcl-10 gene, and translocation t(11;18) involving a novel gene called MLT1, both result in activation of the crucial transcription factor NF-kappaB. These genetic events seem specific in that they have been observed only in MALT lymphomas. Once present, at least the more frequently observed translocation t(11;18) renders cells resistant to cure of Hp infection. Another clinically important question is that in many patients in complete remission after cure of Hp infection, detection of minimal residual disease is positive. Whether these cells are normal memory B cells (with the identical B-cell rearrangement as the original lymphoma clone), or dormant lymphoma cells, is unclear at present. In patients not responding to cure of Hp infection, several treatment options are discussed. MALT lymphomas have opened up a new discussion of lymphoma biology and have thus been called a model disease.

[New diagnostic approaches in malignant B-cell lymphomas]

The new WHO classification of B-cell neoplasms published in 2001 gathers leukaemia and lymphoma. This classification highlights the stage of differentiation of the tumour cell. It groups B-cell neoplasms morphology, histology (nodular or diffuse pattern, cell morphology), immunophenotypes, cytogenetic, molecular abnormalities and clinical data. Recent advances of the normal B cell differentiation understanding and the development of new types of analysis have shown that mature B-cell neoplasms appear to recapitulate stages of normal B-cell differentiation, leading to such a new classification.

Prognostic value of bcl-6, CD10 and CD38 immunoreactivity in stage I-II gastric lymphomas: identification of a subset of CD10+ large B-cell lymphomas with a favorable outcome

bcl-6, CD10 and CD38 are useful markers for identifying 2 molecularly and prognostically distinct profiles of diffuse large B-cell lymphomas (LCLs), defined as germinal-center B-like and activated B-like. We investigated the prognostic role of bcl-6, CD10 and CD38 immunoreactivity in 102 gastrectomized patients with primary gastric lymphomas (PGLs). There were 41 low-grade marginal zone lymphomas of MALT-type (LGML) and 61 diffuse large B-cell lymphomas with (DLCLMLs; n = 31) or without (DLCLs; n = 30) an LGML component. bcl-6, CD10 and CD38 were significantly more commonly expressed in DLCL or DLCML as compared with LGML (50% vs. 48% vs. 17%, p = 0.0002 for bcl-6; 27% vs. 26% vs. 0%, p = 0.0004 for CD10; 45% vs. 48% vs. 13%, p = 0.0005 for CD38, respectively). CD10 immunoreactivity was independently associated with a better survival in diffuse LCL patients (5-year overall survival: 88% +/- 8% vs. 66% +/- 7%; p = 0.04); bcl-6 or CD38 immunoreactivities did not disclose any prognostic implication. Age, presence of LGML component, lactic dehydrogenase serum levels and use of chemotherapy were additional independent prognostic factors. We conclude that CD10 immunoreactivity assessment could be a clear, easy-to-interpret and reliable prognostic factor in PGL. Accordingly, patients with CD10(+) gastric large B-cell lymphomas may be at reduced risk and eligible for clinical trials evaluating more conservative therapeutic options.

A gene expression-based method to diagnose clinically distinct subgroups of diffuse large B cell lymphoma

To classify cancer specimens by their gene expression profiles, we created a statistical method based on Bayes' rule that estimates the probability of membership in one of two cancer subgroups. We used this method to classify diffuse large B cell lymphoma (DLBCL) biopsy samples into two gene expression subgroups based on data obtained from spotted cDNA microarrays. The germinal center B cell-like (GCB) DLBCL subgroup expressed genes characteristic of normal germinal center B cells whereas the activated B cell-like (ABC) DLBCL subgroup expressed a subset of the genes that are characteristic of plasma cells, particularly those encoding endoplasmic reticulum and golgi proteins involved in secretion. We next used this predictor to discover these subgroups within a second set of DLBCL biopsies that had been profiled by using oligonucleotide microarrays [Shipp, M. A., et al. (2002) Nat. Med. 8, 68-74]. The GCB and ABC DLBCL subgroups identified in this data set had significantly different 5-yr survival rates after multiagent chemotherapy (62% vs. 26%; P < or = 0.0051), in accord with analyses of other DLBCL cohorts. These results demonstrate the ability of this gene expression-based predictor to classify DLBCLs into biologically and clinically distinct subgroups irrespective of the method used to measure gene expression.

An Unusual Cause of New-onset Atrial Flutter: Primary Cardiac Lymphoma

Primary cardiac lymphoma is a rare disease with a high mortality rate due to the advanced stage of myocardial involvement at presentation. The diagnosis is extremely difficult to make because of the rarity of the disease, variability of clinical manifestations, limited noninvasive diagnostic techniques available, and difficulties and/or delays in the use of invasive measures. The incidence of the disease is increasing, especially among immunocompromised patients, with those suffering from acquired immunodeficiency syndrome accounting for the greatest increase. We report the case of an immunocompetent 76-year-old black woman who presented with near-syncopal episodes. Transthoracic echocardiogram revealed a right atrial mass. Surgical resection was performed, and a diagnosis of large B-cell non-Hodgkin's lymphoma was made. Primary cardiac lymphoma should be considered in any patient with a cardiac mass. Prompt diagnosis and treatment of primary cardiac lymphoma is imperative for survival.

[Clinical evaluation of mediastinal hematologic malignancies (lymphoma and granulocytic sarcoma)]

In a retrospective review of all patients who visited our hospital between January 1997 and December 2001, we identified 22 with mediastinal lymphoma or mediastina granulocytic sarcoma. They represented 24.2% of the 91 patients with mediastinal tumors. Histology revealed 6 cases of diffuse large B-cell lymphoma, 6 of lymphoblastic lymphoma, 6 of Hodgkin's disease, 2 of granulocytic sarcoma, and 1 of lymphoplasmacytic lymphoma. More than 1/3 of the tumors had highly aggressive histological pictures. Immunocytochemical analysis of cell surface markers by flow cytometry was very useful for reaching a definitive diagnosis of these tumors. In two cases, definitive diagnosis could be obtained only by flow cytometric examination of pleural or pericardial effusion. Careful attention should be paid to the relatively high incidence of hematologic malignancies in mediastinal tumors. Early and accurate diagnosis of these tumors is essential because some of these patients require immediate treatment by hematology specialists.

DNA sequence profile of TP53 gene mutations in childhood B-cell non-Hodgkin's lymphomas: prognostic implications

OBJECTIVES

The TP53 gene encodes a nuclear protein implicated in the regulation of the cell cycle, DNA repair, and apoptosis. TP53 mutations and other alterations have been described in numerous types of tumors, and some of these have been associated with poor prognosis. The aim of this study was to characterize TP53 mutations in childhood B non-Hodgkin's lymphoma, their correlation with clinical prognostic factors and response to therapy.

PATIENTS AND METHODS

Samples from 49 children with B non-Hodgkin's lymphoma were examined for TP53 alterations by single-strand conformation polymorphism analysis (SSCP) of exons 5-9, direct sequencing and by p53 immunohistochemistry.

RESULTS

Mutations of TP53 were detected in 11 of 49 (22.5%) patients and more specifically in 20% of Burkitt's lymphoma. The sequence analysis showed missense mutations in 10 cases and an insertion mutation in one case. Mutations of the transition type occurred more frequently than transversions (seven of 11). Analysis of the spectrum of single-nucleotide substitutions showed a 30% frequency of transition mutations in CpG dinucleotide sequences. The overall frequency of p53 immunostaining positivity was 36% (15 of 41). There was a very good agreement between protein expression and the presence of TP53 mutation (P=0.0005). No significant correlation was found regarding age, gender, clinical stage and LDH level and TP53 mutations. Comparison of EFS curves using the log-rank test were also not significant. However, the analysis of the effects of mutations on the core p53 structure identified biological and biochemical mutants with phenotypes probably related to different response to chemotherapy.

CONCLUSIONS

Our data suggest that some types of mutants can alter the protein distinctly and may be associated with a more aggressive phenotype. In addition, the impact of TP53 mutations on response to therapy may also be influenced by disruption of other genes.