Intravascular lymphomatosis (malignant angioendotheliomatosis). A B-cell neoplasm expressing surface homing receptors

We report the clinical and immunohistochemical features of six cases of intravascular lymphomatosis. All patients presented with symptoms referable to central nervous system (CNS) involvement. In two patients, the diagnosis was made on brain biopsy specimens. In the remaining four cases, diagnosis was made at autopsy. Three of the four autopsied patients had focal extravascular lymphoma, diffuse large cell type. In all five cases tested, immunohistochemical stains on paraffin-embedded sections confirmed the lymphoid nature of the malignant cells. Stains on frozen sections in one case, and on paraffin-embedded tissue in the other four cases, demonstrated B-lymphocyte lineage. In the remaining case, electron microscopy confirmed the lymphoid nature of the tumor cells. All three cases tested expressed the Hermes 3-defined homing receptor antigen and lacked peanut agglutinin receptors. Our results are consistent with other reports confirming the lymphoid nature of so-called malignant angioendotheliomatosis. Our limited analysis of surface receptor molecules suggests that the expression of the homing receptor for high endothelial venules is not in itself responsible for the unusual intravascular location of these cells.

Mediastinal large cell lymphoma. An uncommon subset of adult lymphoma curable with combined modality therapy

Thirty adults with large cell lymphoma predominantly localized to the mediastinum diagnosed at the Massachusetts General Hospital between 1976 and 1985 were identified. The median age of the 20 females and 10 males was 34 years. All but one presented with symptoms due to an enlarging mediastinal mass, which was localized in 22 patients (73%) and exceeded 10 cm in maximal diameter in 65%. Superior vena cava syndrome and large pleural and pericardial effusions were common. Employing CHOP chemotherapy (cyclophosphamide, doxorubicin, vincristine, prednisone) and consolidation radiation therapy in most cases, 80% achieved a complete remission and 59% survive failure-free at 5 years by actuarial calculation. The size of the mediastinal mass adversely affected failure-free survival (89% vs. 40%, P less than 0.05). No other pretreatment risk factor predicted outcome, but more intense chemotherapy was associated with improved survival (P = 0.035). Large cell mediastinal lymphoma is a locally invasive, often bulky malignancy with a predilection for young women; disease of low or moderate bulk is curable with full dose CHOP chemotherapy and consolidation radiation, but bulky disease requires more aggressive treatment.

Alternative birth positions

The dorsal supine position for birth appears to be an aberration practised only in North America during the last 150 years and contrasting to historical precedent and current practices in most other cultures. Alternative birth positions featuring reclining, sitting, squatting or side-lying have recently been shown to have definite physiological and psychological advantages over the conventional posture. The author of this article examines the evidence supporting these advantages and illustrates how these birthing positions may be incorporated into hospital birthing procedures.

The influence of ranitidine on the pharmacokinetics and toxicity of doxorubicin in rabbits

The influence of ranitidine on the pharmacokinetics and toxicity of doxorubicin was studied in six female New Zealand white rabbits. Plasma pharmacokinetic data were first obtained from rabbits given 3 mg/kg doxorubicin. After 1 month, the same rabbits were treated with ranitidine, 2.5 mg/kg or 25 mg/kg, before and during doxorubicin administration. The plasma doxorubicin assays to determine pharmacokinetic parameters were repeated. Drug toxicity was evaluated using complete blood counts, and hepatic function was measured using a 14C-aminopyrine breath test. High-dose ranitidine increased the total exposure to doxorubicin (area under the curve of doxorubicin alone = 1.44 +/- 0.88 microM.h/ml vs 4.49 +/- 2.35 microM.hr/ml for doxorubicin given with high-dose ranitidine; P = 0.06). Low-dose ranitidine did not alter doxorubicin pharmacokinetics. Exposure to doxorubicinol was altered by either high-dose or low-dose ranitidine. 14C-Aminopyrine half-life was altered by a ranitidine dose of 25 mg/kg (aminopyrine half-life after placebo control = 97 +/- 6 min as against aminopyrine half-life after ranitidine = 121 +/- 7 min; mean +/- SEM; P less than 0.02). Low-dose ranitidine did not exacerbate doxorubicin-induced myelosuppression. High-dose ranitidine enhanced doxorubicin-induced erythroid suppression while sparing the myeloid series. At cytochrome P-450-inhibitory doses, ranitidine's effects upon doxorubicin plasma pharmacokinetics are similar to those previously seen with cimetidine. These changes did not appear to alter drug detoxification and are not related to microsomal inhibition of doxorubicin detoxification. Low doses of ranitidine do not alter doxorubicin plasma pharmacokinetics or toxicity in rabbits.

Computed tomography in the evaluation of lymphoma of the uterine cervix

Primary involvement of the uterine cervix is a rare presentation of extranodal lymphoma. The clinical and computed tomography findings are described in four patients ranging from 23 to 74 years of age. All presented with vaginal bleeding. Computed tomography findings were similar to those of other primary pelvic neoplasms, with diffuse uterine enlargement and lobular contour alteration often mimicking fibroids. Lymphadenopathy was not observed in comparison to secondary lymphoma of the female genitalia. All patients had excisional biopsies. One patient had an initial TAH and BSO. Histology was varied with one case of large cell lymphoma, one of diffuse histiocytic, one of unclassifiable poorly differentiated lymphoma, and one of nodular poorly differentiated lymphocytic lymphoma that was finally classified as granulocytic sarcoma. Disease extent could be assessed by computed tomography and aided treatment planning. In conclusion, computed tomography was found to be useful in the evaluation of uterine lymphoma. Although the findings are not specific, the local tumor extent can be evaluated at the same time as other sites of potential involvement.

Kimura's disease and angiolymphoid hyperplasia with eosinophilia: two distinct histopathological entities

The relationship between the disorder known in Japanese and Chinese literature as Kimura's disease and that known in Western literature as angiolymphoid hyperplasia with eosinophilia (ALHE) has been the subject of debate. Many reports have used the terms synonymously. We have reviewed the histological and clinical features of 4 cases, all occurring in Caucasians, 2 of which are typical of Kimura's disease and 2 of ALHE. Analysis of the cases indicates that the histological features of the 2 disorders are sufficiently different to warrant their recognition as 2 distinct entities. The histological and clinical features of Kimura's disease are most consistent with an allergic or autoimmune process in which blood vessels, lymphocytes and eosinophils participate. Those of ALHE suggest a primary, probably neoplastic disorder of vascular endothelium with a variable and secondary inflammatory response. Although there is some clinical overlap between patients with the 2 disorders, the histological features are distinctive, and the 2 terms should not be used synonymously.

Effect of allyl alcohol-induced sublethal hepatic damage upon doxorubicin metabolism and toxicity in the rabbit

A model of hepatic dysfunction in vivo has been developed in rabbits to determine the effects of sublethal hepatocellular necrosis upon doxorubicin pharmacology. Eight New Zealand white rabbits were given 3 mg/kg doxorubicin i.v. Plasma doxorubicin and metabolite pharmacokinetics were determined and toxicity assessed by nadir complete blood counts. Hepatic function was assessed by the pulmonary excretion rate of 14CO2 from [14C]aminopyrine. Hepatocellular necrosis was produced by i.v. injection of 1.35 mg/kg of a 2% allyl alcohol solution. Doxorubicin administration and pharmacokinetics were repeated. Doxorubicin enhances the hepatotoxicity of allyl alcohol. Hepatocellular necrosis does not alter the plasma pharmacokinetics of doxorubicin but does increase the plasma exposure of doxorubicinol. Doxorubicin-induced myelosuppression is enhanced by allyl alcohol pretreatment. These data suggest that in circumstances of reduced hepatocellular volume or acute hepatocellular necrosis, a key plasma marker of doxorubicin-induced acute toxicity may be doxorubicinol.

Immunoglobulin gene rearrangements in adult non-Hodgkin's lymphoma

Southern blotting was employed to analyze the immunoglobulin heavy and light chain genes and the gene for the T cell receptor beta chain in genomic DNA derived from the tumor specimens of 120 adults with pathologically classified and immunotyped non-Hodgkin's lymphoma and B cell chronic lymphocytic leukemia. In a consecutive series of 100 patients, one or two rearranged heavy chain genes could be detected in each of the 80 samples expressing clonal surface immunoglobulin. The kappa gene was rearranged in 70 percent of kappa-bearing tumors and in 23 percent of lambda-bearing specimens. Furthermore, a rearranged immunoglobulin gene was also observed in 21 of 29 lymphomas (nine from the consecutive series and 20 selected for surface immunoglobulin-negative status) in which B cell lineage was in doubt because of absent clonal surface immunoglobulin. These findings indicate that most cases of lymphoma and lymphocytic leukemia in adults are of B cell lineage, even when phenotypic evidence is inconclusive. The exceptional cases (only 3 percent in the consecutive series) were of either follicular lymphoma or diffuse large cell (histiocytic) lymphoma subtype; the lineage in cases of diffuse lymphocytic lymphoma or chronic lymphocytic leukemia was never in doubt. Although the convenience of surface marker analysis assures its continuing clinical application, gene study resolves indeterminate cases and extends the understanding of the pathogenesis of lymphoproliferative disease.

Systemic salmonellosis in patients with disseminated histoplasmosis. Case for 'macrophage blockade' caused by Histoplasma capsulatum

Five patients are described with disseminated histoplasmosis and systemic salmonellosis. Four of these patients were also immunocompromised because of the acquired immunodeficiency syndrome in two patients and renal transplantation in another two patients. Histologic studies in two patients showed histiocytes that were heavily laden with Histoplasma capsulatum yeast-phase organisms. We postulate that diffuse parasitization of the reticuloendothelial system (RES) by Histoplasma organisms may cause "RES blockade," which then predisposes to systemic salmonellosis, as reported in certain other infections and in sickle cell anemia.

"Plasmacytoid T cells" in Castleman's disease. Immunohistologic phenotype

Plasmacytoid T cells in two cases of Castleman's disease were stained with a panel of monoclonal antibodies to hematopoietic cell-associated antigens, using an immunoperoxidase technique on frozen sections. The immunohistologic phenotype of these cells was T4/Leu-3+, HLA-DR+, T1/Leu-1-, T3/Leu-4-, T8/Leu-2-, T11/Leu-5-, B1-, B2-, Leu-14-, Ig-, CALLA-, OKM1-, Leu-M1-. In contrast to plasma cells of B lineage, plasmacytoid T cells were T200+, T10-. The phenotype was similar to that of two previously reported lymphomas of plasmacytoid T cells. Plasmacytoid T cells appear to be a unique subset of lymphoid cells, whose function remains to be established.

Relapsing central and peripheral demyelinating diseases. Unusual pathologic features

We treated a patient who had a demyelinating peripheral neuropathy and a central nervous system inflammatory demyelinating disease. The unusual pathologic feature of dense infiltrates of atypical macrophages was observed in many areas of the brain; otherwise the process had several features in common with either multiple sclerosis or chronic relapsing experimental allergic encephalomyelitis. The illness followed "swine-flu" inoculation; exacerbation followed pneumococcal vaccination.

Endobronchial involvement with non-Hodgkin's lymphoma. A clinical-radiologic analysis

Based on experience with three cases of endobronchial non-Hodgkin's lymphoma and a review of cases previously reported, two patterns of lymphomatous involvement of airways are described. The Type 1 pattern is characterized by diffuse submucosal infiltrates occurring in the presence of intra- and extrathoracic lymphoma. In Type 2 cases, central airways are involved by a solitary mass in the absence of clinically apparent systemic lymphoma. The clinical-radiologic picture is characterized by signs of pneumonitis in Type 1 cases, while in Type 2 cases, signs of airway obstruction uniformly occur.

Malignant lymphoma of the thyroid gland: a clinical and pathologic study of twenty cases

Among 20 patients with malignant lymphoma of the thyroid gland, the mean age at diagnosis was 63 years and the male to female ratio was 1:6. All patients had a firm, rapidly enlarging neck mass. In 90% of the patients the mass had been present for less than 1 year; in 40%, for less than 1 month. Approximately half of the patients tested had hypothyroidism; three fourths had elevated antithyroid antibodies. There was one nodular lymphoma. The remaining 17 cases available for review were diffuse. Thyroid lobectomy was performed in seven patients, limited excision in eight, and needle biopsy alone in five. External irradiation was administered in 11 cases (55%). Chemotherapy was used alone in one patient (5%) and in combination with radiotherapy in eight (40%). Six patients (30%) were alive without evidence of recurrent disease at follow-up ranging from 1 to 12 years. Eleven patients had died of lymphoma, all but one dying within 1 year. One patient died of other causes and two were lost to follow-up study. There was no appreciable effect of patient age or sex, lymphoma histology, or extent of surgical resection on survival. Treatment of choice for primary lymphoma of the thyroid gland appears to be external irradiation or chemotherapy, alone or in combination. The role of surgery is limited to making a tissue diagnosis of lymphoma, unless the tumor is completely intrathyroidal.

Lymphoma-like lesions of the lower female genital tract: a report of 16 cases

The microscopic differential diagnosis of malignant lymphoma and benign lymphoid infiltrates in the lower female genital tract may be difficult. We have reviewed the clinical and pathological features of 16 lymphoma-like lesions of the cervix (10 cases), endometrium (five cases), and vulva (one case) and compared these features with those of malignant lymphoma. One patient with a cervical lesion and one with a vulvar lesion had infectious mononucleosis. Microscopic examination of the lesions revealed an infiltrate of large lymphoid cells with prominent mitotic activity, including cleaved and noncleaved follicular center cells and immunoblasts; a starry-sky pattern was present in three cases. Plasma cells, polymorphonuclear leukocytes, and small lymphocytes were present within the infiltrate in many of the cases. Immunohistochemical stains were performed in seven cases. In six they indicated the presence of polyclonal plasma cells; most of the atypical large cells did not stain for cytoplasmic immunoglobulin. In the seventh specimen many immunoblasts had cytoplasmic staining of polyclonal type. The microscopic features of the lesions differ from those of lymphomas. Surface ulceration and intralesional acute inflammatory cells and plasma cells are rarely seen in lymphomas, while a large size, deep invasion, cellular monomorphism, and prominent sclerosis were not seen in the reactive lymphoma-like lesions. Follow-up of from 6 months to 12 years was available for 10 of the 16 patients, nine of whom were treated by procedures inadequate for the cure of malignant lymphoma, and has been uneventful in all of them. The clinical and pathologic features of these cases suggest that the atypical appearances in most of them resulted from a focally florid lymphoid proliferation in association with chronic cervicitis or endometritis, or a generalized disorder of lymphoid cells such as infectious mononucleosis.

Mantle-zone lymphoma. A pattern produced by lymphomas of more than one cell type

We analyzed the distribution and immunologic phenotype of the neoplastic cells in eight cases of mantle-zone lymphoma. Although in all the cases the follicle centers appeared reactive on routine histologic examination, polyclonal staining for immunoglobulin was found in the follicle centers in only five of the eight cases; in the other three cases the follicle centers were monoclonal. In three cases, the immunologic phenotype was that of centrocytic (diffuse small cleaved cell) lymphoma: IgM+IgD+B1+B2+Ia+Tl+. In one case the phenotype was that of a follicular (centroblastic/centrocytic) lymphoma: IgG+B1+B2+Ia+CALLA+. In the other four cases, the phenotype was IgM+B1+B2+ or B2-Ia+; this phenotype can be seen in diverse B cell lymphomas. The phenotype of normal mantle-zone cells (IgM+IgD+B1+B2+Ia+) was not reproduced by any of the lymphomas. A mantle-zone pattern may be produced by either follicular or diffuse lymphomas of predominantly small cleaved cell type, and does not indicate an origin from the cells of the normal mantle zone.

B-cell neoplasms of the lymphocytic, lymphoplasmacytoid, and plasma cell types: immunohistologic analysis and clinical correlation

The relation between chronic lymphocytic leukemia (CLL, lymphocytic lymphoma (SL), plasmacytoid lymphocytic lymphoma (LP), plasmacytoma (PL), and multiple myeloma (MM) was investigated with cryostat sections stained with antibodies to immunoglobulin heavy and light chains and the B-cell differentiation antigens B1, B2, Ia, T1, and CALLA. Neoplasms were subclassified according to plasmacytoid features, leukemia (CLL) site of involvement (nodal or extranodal), serum monoclonal immunoglobulin, or clinical evidence of MM. The results defined two groups of lymphocytic lymphomas without plasmacytoid features (16 cases). Ten of these lymphomas were associated with CLL. Nine involved lymph nodes, all expressed IgM, five expressed IgD, nine were B2-positive, eight were T1-positive, and all were B1- and Ia-positive. Six of the lymphomas were not associated with CLL. Five of these tumors were extranodal, all were T1- B1+ B2- Ia+, five expressed IgM without IgD, and one contained IgG. These differences in clinical and immunologic phenotypes suggest that CLL and SL without CLL may be related to different stages of B-cell differentiation. T1 appeared to be a marker for CLL, since all T1-positive neoplasms were leukemic. Lymphomas with plasmacytoid features (ten cases) were more often extranodal, and none was leukemic. The immunologic phenotypes were heterogeneous: all of these lymphomas were T1-negative, most were IgM+ IgD-, three were B2-positive, and all were Ia-positive. The plasma cells in five lymphomas with marked plasmacytoid features were B1-negative; they were Ia-positive in four and Ia-negative in one. These data suggest that LP is a heterogeneous group, reflecting B cells at diverse stages of differentiation. Ten plasmacytomas, nine of which were associated with MM, differed from LP in showing heavy chain class switching; all were T1- B1- B2-, and all but one were Ia-negative. These results are consistent with the existence of two pathways or stages of B-cell differentiation: one that generates IgM-producing plasma cells, as seen in the primary immune response or in response to pokeweed mitogen, and one that generates IgG- or IgA-positive plasma cells, as seen in the late primary or secondary immune response. Plasmacytoid lymphocytic lymphoma reflects the first, while PL/MM reflects the second pathway. B1 appears to be lost before Ia in terminal plasma cell differentiation.

Thymic cysts in mediastinal Hodgkin disease

Three cases of proved thymic cysts associated with mediastinal Hodgkin disease are presented. Two illustrate regression of lymphoma with chemotherapy but persistence of thymic cysts. The third case demonstrates a thymic cyst in untreated Hodgkin disease. These cases suggest that such cysts are probably neither coincidental with nor a consequence of therapy but are probably related to initial thymic involvement by Hodgkin disease.

The predominant lymphocyte in most thymomas and in nonneoplastic thymus from patients with myasthenia gravis is the cortical thymocyte

Cell suspensions prepared from 12 specimens of nonneoplastic thymus (6 normal and 6 from patients with myasthenia gravis) and from 17 thymomas were investigated with a panel of monoclonal antibodies. The great preponderance of thymocytes from the 12 nonneoplastic specimens and from 13 of the 17 thymomas (2 of 3 predominantly lymphocytic tumors and 11 of 12 mixed tumors) displayed the surface phenotype of cortical or common thymocytes. These cells formed rosettes with unsensitized sheep erythrocytes (E-rosettes) at both 4 and 37 degrees C, and reacted with the following monoclonal antibodies: OKT1 (thymic and peripheral T cells), OKT6 (common thymocytes), OKT10 (replicating lymphoid cells), OKT11 (sheep cell receptor), and both OKT4 (inducer-helper T cells) and OKT8 (cytotoxic-suppressor T cells). Few B cells (lymphocytes with either immunoglobulin or Ia-like antigen on the cell surface), and few cells with receptors for transferrin and interleukin 2 were detected. Thymocytes from 3 of the 4 remaining thymomas (2 predominantly epithelial tumors and 1 mixed tumor) displayed surface marker characteristics of medullary thymocytes or peripheral T cells; i.e., they were reactive with OKT1, OKT3 (peripheral T cells), OKT11, and either OKT4 or OKT8, and were also E-rosette positive only at 4 degrees C and TdT negative. Thymocytes from the final tumor, a lymphocytic thymoma, exhibited an intermediate phenotype. Thus, almost all mixed (11 of 12) and lymphocytic (2 of 3) thymomas were composed predominantly of cortical thymocytes, while the medullary cell was the rule in the two tumors that were predominantly epithelial.

Malignant lymphoma presenting as Kaposi's sarcoma in a homosexual man with the acquired immunodeficiency syndrome

A homosexual man had Kaposi's sarcoma of the skin and lymph nodes. After a brief response to interferon, the patient developed new skin lesions. Massive bleeding in the gastrointestinal tract prompted endoscopy, which showed tumor involvement of the stomach, believed to be Kaposi's sarcoma. At autopsy, a diffuse lymphoma was found involving the skin and gastrointestinal tract, forming collision tumors in regions that contained Kaposi's sarcoma. Lymphomatous tissue, but not uninvolved lymph node or spleen, contained Epstein-Barr virus DNA, as shown by DNA hybridization studies. Epstein-Barr virus may play a role in the development of lymphoma in immunosuppressed patients. Unusual manifestations of tumors, such as the massive gastrointestinal bleeding seen in this case, may indicate the development of a second neoplasm.

Diffuse large cell (histiocytic) lymphoma of the spleen. Clinical and pathologic characteristics of ten cases

Ten patients with diffuse large cell (histiocytic) lymphoma of the spleen had a characteristic clinical presentation and pathologic findings. Patients presented with left upper quadrant pain, fever, weight loss, and an elevated sedimentation rate. Imaging studies revealed an enlarged spleen with a discrete mass in all cases. Moderate to massive splenomegaly (average weight, 1025 g) was found at laparotomy; a single large mass or multiple confluent nodules with extensive central necrosis replaced 85% to 90% of the parenchyma. The tumor transgressed the splenic capsule in nine of ten cases, and either invaded or was adherent to the diaphragm, stomach, pancreas, or abdominal wall. Lymph nodes in the splenic hilum or retroperitoneum were frequently involved. Seven patients were in Ann Arbor Stage II, and three were in Stage I. Eight of the ten lymphomas were subclassified as centroblastic (large noncleaved cell) and two were immunoblastic. The B-cell lineage of six tumors was established by the presence of monoclonal immunoglobulin. Despite combination chemotherapy, with or without radiation, three of the seven patients whose follow-up was adequate died in less than 2 years; four are alive at 7, 12, 12, and 81 months, respectively, the last two with recurrent lymphoma. Large cell lymphoma of the spleen is a likely diagnosis in patients who present with left upper quadrant pain, fever, and radiographic evidence of a splenic mass.

Diffuse large cell (histiocytic) lymphoma of the spleen. Clinical and pathologic characteristics of ten cases

Ten patients with diffuse large cell (histiocytic) lymphoma of the spleen had a characteristic clinical presentation and pathologic findings. Patients presented with left upper quadrant pain, fever, weight loss, and an elevated sedimentation rate. Imaging studies revealed an enlarged spleen with a discrete mass in all cases. Moderate to massive splenomegaly (average weight, 1025 g) was found at laparotomy; a single large mass or multiple confluent nodules with extensive central necrosis replaced 85% to 90% of the parenchyma. The tumor transgressed the splenic capsule in nine of ten cases, and either invaded or was adherent to the diaphragm, stomach, pancreas, or abdominal wall. Lymph nodes in the splenic hilum or retroperitoneum were frequently involved. Seven patients were in Ann Arbor Stage II, and three were in Stage I. Eight of the ten lymphomas were subclassified as centroblastic (large noncleaved cell) and two were immunoblastic. The B-cell lineage of six tumors was established by the presence of monoclonal immunoglobulin. Despite combination chemotherapy, with or without radiation, three of the seven patients whose follow-up was adequate died in less than 2 years; four are alive at 7, 12, 12, and 81 months, respectively, the last two with recurrent lymphoma. Large cell lymphoma of the spleen is a likely diagnosis in patients who present with left upper quadrant pain, fever, and radiographic evidence of a splenic mass.

Immunohistologic characterization of two malignant lymphomas of germinal center type (centroblastic/centrocytic and centrocytic) with monoclonal antibodies. Follicular and diffuse lymphomas of small-cleaved-cell type are related but distinct entities

The relationship between follicular lymphomas and diffuse lymphomas of small-cleaved-cell type was investigated with the use of a panel of antibodies against B-cell differentiation antigens. Follicular lymphomas, regardless of histologic subtype, were immunologically homogeneous: Ig+ B1+ B2+ CALLA+ Ia+. Two cases were Ig-negative, and 4 were CALLA-negative. Diffuse small-cleaved-cell (centrocytic) lymphomas were more heterogeneous. The majority were Ig+ B1+ B2+ Ia+ T1+ CALLA-. A minority were B2-negative, T1-negative, or CALLA-positive. An increased frequency of Ig heavy chain class switching and loss of T1 antigen suggest that follicular lymphomas are at a later stage of differentiation than most centrocytic lymphomas. The differences in immunologic phenotype provide further justification for a classification that distinguishes between follicular and diffuse lymphomas of small-cleaved-cell types. The expression of Ig, Ia, B1, and B2 on neoplastic follicular center cells correlates with expression of these antigens on normal B cells. In addition, anti-B2 appears to stain a nonlymphoid dendritic cell present in normal germinal centers and in both follicular and diffuse germinal center cell lymphomas in this study. In follicular lymphomas, the dendritic pattern was similar to that of normal follicles, while in centrocytic lymphomas a more irregular dendritic pattern was seen. Dendritic staining was seen in both nodal and extranodal lymphomas, suggesting that these nonlymphoid cells either migrate with neoplastic B cells or are present in a variety of normal tissues.

Scintigraphic findings in large-cell lymphoma of the spleen: concise communication

The scintigraphic findings from eight patients who underwent splenectomy for splenomegaly secondary to diffuse large-cell lymphoma are described. Large focal photopenic areas were found in all cases, either solitary or multiple. The appearance is relatively typical for large-cell lymphoma, which should be strongly considered in a nontraumatized patient who presents with painful splenomegaly of unknown origin.

Radiation therapy of Waldeyer's ring lymphoma

Forty-nine patients with biopsy-proven Waldeyer's ring lymphoma were treated with radiation therapy between 1968 and 1979; 45 to 50 Gy were given to Waldeyer's ring structures with a 5- to 10-Gy boost to the primary site. Uninvolved low cervical nodes received 40 to 50 Gy. Chemotherapy was reserved for treatment failures. Actuarial 5-year survival was 53%, disease-free survival was 48%, and local control was 98%. Patients with Stage I disease fared better than patients with Stage II disease, and unilateral adenopathy conferred a better prognosis than bilateral adenopathy. When classified by the Rappaport system, nodular lymphomas had a better prognosis than diffuse lymphomas, and of the diffuse lymphomas, histiocytic lymphoma was a more lethal disease than lymphocytic lymphoma. Patients with diffuse undifferentiated lymphomas in the Rappaport system, or high-grade lymphomas in the Working Formulation, fared poorly. Most relapses were systemic, and actuarial 5-year survival after salvage was only 20%. A logical approach to the treatment of this disease can be based on these prognostic features.

Lymphocyte surface markers in orbital lymphoid neoplasms

Since the malignant nature of many orbital lymphoid infiltrates is difficult to assess from pathologic examination alone, over the past four years lymphocyte surface marker studies have been added to the evaluation of 23 such cases. Only 10 of the 23 could be confidently classified as malignant lymphoma by histology alone. However, monoclonal surface immunoglobulin was found in 15, supporting the pathologic diagnosis of malignancy in eight and adding seven that could not have been diagnosed otherwise. Clinical evaluation, including a median follow-up of 18 months, revealed manifestations of systemic lymphoma in six of those 15; two had been diagnosed only by surface markers. In contrast, only one of eight cases lacking monoclonal surface immunoglobulin exhibited clinical evidence of malignancy (that case was also indeterminate by histologic criteria). The addition of surface marker analysis permits more accurate diagnosis of orbital lymphoma than is possible from pathologic study alone. This technique can suggest the subtype of lymphoma.

Malignant lymphoma and granulocytic sarcoma of the uterus and vagina. A clinicopathologic analysis of 27 cases

Twenty-five cases of malignant lymphoma of the uterine corpus or cervix and the vagina, and one case of granulocytic sarcoma of the cervix were analyzed. The patients typically presented with vaginal bleeding and a subepithelial mass without obvious ulceration or other epithelial abnormality. Twenty-one of the 27 tumors appeared to originate in the cervix, 4 in the vagina, and 2 in the endometrium. Seven of them were nodular lymphomas, 17 diffuse large cell, or "histiocytic" lymphomas, 1 was a Burkitt's tumor, and 2 were granulocytic sarcomas. Sclerosis was a prominent histologic feature in lymphomas of the cervix and vagina. Twenty-one patients had disease confined to a single extranodal site (Ann Arbor Stage IE), and six had lymph node or ovarian involvement (Stages IIE + IV). The overall actuarial 5-year survival was 73%. The survival of patients with Stage IE tumors was 89%, compared with 20% for patients with lymph node or ovarian involvement. None of the 12 patients with Stage IE lymphoma of the cervix or vagina who received definitive initial local treatment (surgical and/or radiation therapy) relapsed. Nodular lymphomas and diffuse lymphomas with a preponderance of large cleaved cells were more often localized and had a better prognosis than large or small noncleaved and immunoblastic types. Lymphoma of the lower female genital tract is a rare, but treatable malignancy, which must be distinguished microscopically from inflammatory lesions and nonlymphoid tumors arising in this site.

Characterization of immature sinus histiocytes (monocytoid cells) in reactive lymph nodes by use of monoclonal antibodies

The distinctive mononuclear cells that appear in the cortical sinuses of lymph nodes in toxoplasma lymphadenitis and other conditions have been termed "immature sinus histiocytes," although these cells have neither enzyme histochemical nor ultrastructural features of histiocytes. The authors stained these cells in frozen sections of six reactive lymph nodes, using the immunoperoxidase technique, with monoclonal antibodies to T cell, B cell, and monocyte antigens and with heteroantisera to immunoglobulin and lysozyme. The immature sinus histiocytes stained with a monoclonal antibody to B cells (anti-B1) and had immunoglobulin of the IgG class. They did not react with monoclonal antibodies to T cells or monocytes or with antilysozyme. In contrast, medullary sinus histiocytes in three additional lymph nodes were B1-negative and reacted with anti-T4, anti-M1, and anti-lysozyme. These results indicate that immature sinus histiocytes are IgG-bearing B lymphocytes rather than histiocytes. Their role in the immune response remains enigmatic.

Immunohistologic diagnosis of orbital lymphoid infiltrates

The distinction between benign and malignant lymphoid infiltrates of the orbit may be impossible on routine histopathologic sections. However, the detection of monotypic immunoglobulin is useful in distinguishing neoplastic from benign infiltrates. Since diagnostic frozen sections are often performed on biopsies of orbital masses to determine the adequacy of the biopsy and to provide a preliminary diagnosis, we stained additional frozen sections of 20 predominantly lymphoid infiltrates by an immunoperoxidase technique with antisera to immunoglobulin heavy and light chains. On routine sections, nine cases were malignant lymphoma, three were follicular hyperplasia, and eight (42%) were dense lymphocytic infiltrates of indeterminate nature. The nine lymphomas had monotypic immunoglobulin staining. The three histologically benign lesions had polytypic immunoglobulin. Six of the eight indeterminate lesions had monotypic immunoglobulin, supporting a diagnosis of lymphoma; two had polytypic staining. There was evidence of disseminated lymphoma at the time of diagnosis in five of nine patients with histologically malignant lesions and three of five with monoclonal indeterminate lesions for whom the information was available. Staining with monoclonal antibodies to T-cells revealed variable numbers of T-cells in all cases; their number and distribution did not distinguish benign from malignant lesions. The immunoperoxidase technique on frozen sections permits optimal use of small biopsy specimens for both morphologic and immunologic diagnosis. The majority of histologically indeterminate orbital lymphoid infiltrates were shown to be monoclonal.

Primary gastric lymphoma. An analysis with emphasis on prognostic factors and radiation therapy

Primary gastric lymphoma, lymphoma originating in the stomach, without involvement of peripheral or mediastinal lymph nodes, viscera, or the bloodstream, is sufficiently uncommon that the indications for radiation therapy, the dose of irradiation necessary for control of lymphoma, optimum field size, and patterns of failure have never been established. The authors identified 26 patients, and reviewed their charts and pathologic material. Their overall 5-year survival was 57%. Factors significantly influencing 5-year survival were serosal penetration (32% versus 91%), regional lymph node involvement (33% versus 81%), and location on the lesser curvature (20% versus 89%). Histologic characteristics, extent of surgery, and, provided the patient was irradiated, involvement of surgical margins did not influence survival. Overall, survival was not affected by irradiation, but in patients with poor prognostic factors there appeared to be a beneficial effect. Analysis of local control in this and other series suggests that patients should receive at least 40 Gy, and that whole abdominal irradiation is not necessary. The majority of failures were distant, indicating a need for effective systemic therapy.

Primary gastric lymphoma. An analysis with emphasis on prognostic factors and radiation therapy

Primary gastric lymphoma, lymphoma originating in the stomach, without involvement of peripheral or mediastinal lymph nodes, viscera, or the bloodstream, is sufficiently uncommon that the indications for radiation therapy, the dose of irradiation necessary for control of lymphoma, optimum field size, and patterns of failure have never been established. The authors identified 26 patients, and reviewed their charts and pathologic material. Their overall 5-year survival was 57%. Factors significantly influencing 5-year survival were serosal penetration (32% versus 91%), regional lymph node involvement (33% versus 81%), and location on the lesser curvature (20% versus 89%). Histologic characteristics, extent of surgery, and, provided the patient was irradiated, involvement of surgical margins did not influence survival. Overall, survival was not affected by irradiation, but in patients with poor prognostic factors there appeared to be a beneficial effect. Analysis of local control in this and other series suggests that patients should receive at least 40 Gy, and that whole abdominal irradiation is not necessary. The majority of failures were distant, indicating a need for effective systemic therapy.

Distribution of T-cell subsets in follicular and diffuse lymphomas of B-cell type

The authors examined the number and distribution of cells reacting with monoclonal antibodies to T-cell subsets in frozen tissue sections of B-cell lymphomas (30 follicular and 17 diffuse lymphomas). In five diffuse lymphomas (two lymphocytic, three small cleaved cell) the neoplastic B-lymphocytes reacted with the monoclonal antibody anti-T1. In all other cases, the monoclonal antibodies to T-cell subsets reacted only with small lymphocytes concentrated between the follicles of follicular lymphomas and distributed randomly in diffuse lymphomas. The distribution of T cells and the T4+/T8+ ratio in follicular small cleaved and mixed lymphomas was similar, although not identical, to that seen in hyperplastic lymphoid follicles. Fewer T cells and a decrease in the T4+/T8+ ratio were seen in follicular large cell lymphoma and in diffuse large cell lymphomas. The number and distribution of T cells in follicular lymphomas is consistent with the hypothesis that there is a functional interaction between neoplastic B cells and benign T cells. No tumors were found in which the neoplastic B cells reacted with anti-T3, anti-T4, or anti-T8.

Large-cell lymphoma of the spleen: CT appearance

CT and histopathological findings were correlated in 5 patients with large-cell lymphoma who presented with splenic enlargement. Prominent CT findings included splenomegaly with large solitary or multiple areas of low attenuation. The clinical presentation and operative findings are reviewed.

Monoclonal antibody studies in non-Hodgkin's lymphoma

The cell lineage of suspensions prepared from 85 non-Hodgkin's lymphomas was investigated with a panel of 10 monoclonal antibodies and conventional surface marker techniques. Surface immunoglobulin, assessed with specific heteroantisera, proved to be the most useful characteristic and defined the clonal character and B-cell lineage of 63 specimens: almost all nodular lymphocytic (21 of 22) and diffuse lymphocytic (11 of 13) lymphomas, most diffuse histiocytic (29 of 33) and diffuse mixed (2 of 2) lymphomas, and a few nodular mixed (2 of 12) and nodular histiocytic (0 of 3) lymphomas. Monoclonal antibodies provided useful ancillary surface marker criteria. Thus, positivity with OKT1 (which detects both thymic and peripheral T cells) in the absence of reactivity with monoclonal antisera, which detect only peripheral T cells (OKT3, OKT4, OKT8, and OKT11), was seen only in diffuse lymphocytic lymphoma of B lineage. Ia-like antigen could be demonstrated in all B-cell lymphocytic lymphomas and most B-cell diffuse histiocytic lymphomas. Approximately one-half of diffuse histiocytic lymphomas also reacted with OKT9, which detects the transferrin receptor, while few lymph nodes involved by other conditions displayed this reactivity. Most diffuse histiocytic lymphomas and many non-Hodgkin's lymphomas of other subtypes reacted with OKT10, an antiserum that detects an antigen on replicating lymphoid cells. The lineage of approximately one-fourth of the lymphoma suspensions was not resolved conclusively: In most of these, T lymphocytes predominated with a normal proportion of inducer-helper (OKT4) and cytotoxic-suppressor (OKT8) cells. The inability to establish the clonal character of T-cell proliferation in cell suspensions remains an obstacle to completely defining the lineage of non-Hodgkin's lymphomas.

Primary non-Hodgkin's lymphoma of the mediastinum

Non-Hodgkin's lymphoma localized to the mediastinum and adjacent structures occurred in 12 of 215 (6+) non-Hodgkin's lymphoma patients seen at the Massachusetts General Hospital between 1975 and 1979. Lymphangiography, radionuclide scanning and whole body computerized tomography were used to exclude patients with extrathoracic disease at presentation. Eleven of the 12 patients presented with extensive contiguous extranodal disease (Stage IIE) with involvement of either the pericardium, sternum, chest wall, pulmonary parenchyma or, in four cases, with superior venacaval obstruction. Diffuse large cell lymphoma (eight cases) and diffuse poorly differentiated lymphocytic lymphoma (four cases) were the prevalent histologic subtypes; no instances of lymphoblastic lymphoma without extrathoracic spread were encountered. None of four lymphomas studied could be characterized as either B- or T-cell tumors utilizing conventional surface marker techniques. Ten of the 12 patients achieved complete remissions, either after treatment with combination chemotherapy alone (three patients) or after both chemotherapy and mediastinal irradiation (seven patients). Two of these ten have subsequently relapsed, but median survival has not been reached after a mean period of observation of 28 months. Primary nonlymphoblastic non-Hodgkin's lymphoma of the mediastinum is more common than previously realized, displays aggressive contiguous spread within the chest and responds well to combination chemotherapy with or without adjuvant mediastinal irradiation.

Fibrin deposits in Hodgkin's disease

Fibrin deposits were observed in the involved lymph nodes and/or spleens of 15 patients with Hodgkin's disease by specific immunofluorescence and by electron microscopy. Two basic patterns of fibrin deposition were observed: 1) intercellular deposits, chiefly associated with nonneoplastic-appearing lymphoid cells and 2) deposits associated with the collagen fibers of young connective tissue. In addition, coarse fibrin deposits were observed in areas of necrosis, presumably a non-specific finding. Fibronectin was also observed in intercellular areas, but staining was less intense than for fibrin. Fibrin deposits were also observed in 3 of 6 cases of non-Hodgkin's lymphoma, indicating that the finding is not an exclusive feature of Hodgkin's disease. The pathogenesis and possible significance of fibrin deposition in Hodgkin's disease are related to earlier observations of activation of the coagulation system on neoplasia and cell-mediated immunity and to the possible role of fibrin, fibronectin, and their breakdown products in angiogenesis and fibroplasia.

The distribution of neoplastic and normal B-lymphoid cells in nodular lymphomas: use of an immunoperoxidase technique on frozen sections

The authors used an immunoperoxidase technique for the detection of immunoglobulins in frozen sections of 14 nodular lymphomas and ten reactive lymph nodes. Staining with antisera to the various immunoglobulin heavy and light chains permitted characterization and localization of neoplastic and non-neoplastic lymphoid cells in tissue sections. This technique is useful in the differential diagnosis of nodular lymphoma from follicular lymphoid hyperplasia. Non-neoplastic follicle mantle zones were found in six cases, providing additional evidence for the histogenic relationship between nodular lymphomas and lymphoid follicles. Hum Pathol 13:610-617, 1982.

Demonstration of immunoglobulin in malignant lymphomas. Use of an immunoperoxidase technic on frozen sections

We used an immunoperoxidase technic to detect surface and cytoplasmic immunoglobulin in frozen sections of 46 malignant lymphomas. With the immunoperoxidase technic, differential staining with antisera to the various heavy and light chain classes permitted detection and characterization of monotypic immunoglobulin in frozen sections of 15 of 15 nodular lymphomas and 24 of 31 diffuse lymphomas. The immunoperoxidase technic applied to frozen sections is a convenient and reliable method for the detection of immunoglobulin in lymphoid tissues, which can be performed in a pathology laboratory without the need for special equipment.

T-cell chronic lymphocytic leukemia. Report of a case studied with monoclonal antibody

A previously healthy 74 year old woman presented with T-cell chronic lymphocytic leukemia, lymphadenopathy, hepatosplenomegaly and a mediastinal mass. The circulating lymphocytes were small to medium in size (some with convoluted nuclei) and W rosette-positive; they could be assigned to the inducer-helper subset of T cells with the acid of monoclonal antisera. These cells reacted with OKT3, which detects peripheral T cells; OKT4, which detects the inducer-helper subset of T cells; and OKT11, which detects the sheep cell receptor. It is noteworthy that they were also positive for the la-like antigen found on T cells only after activation. Microscopic examination of a lymph node biopsy specimen revealed a diffuse pattern of pleomorphic large cells characteristic of the T-cell lymphomas and lymphocytic leukemias reported from Japan. However, the lymph node cells lacked the T-cell differentiation antigens present on the circulating lymphocytes. The findings in this case provide insight into the pathogenesis of this unusual disorder and are relevant to our understanding of the spectrum of surface antigens in the more common malignant lymphomas.

Contamination of Hodgkin's disease cell cultures

Several laboratories have recently reported the establishment and characterization of long-term cell lines thought to be related to the neoplastic cell of Hodgkin's disease. Here, Harris et al. discuss evidence that some of these lines are, in fact, not related to Hodgkin's disease but are non-human contaminants.