Pericardial effusion: a rare presentation of adult T-cell leukemia/lymphoma

Isolated cardiac valve involvement in smoldering adult T-cell leukemia/lymphoma

Adult T-cell leukemia/lymphoma (ATLL) is an aggressive mature T-cell neoplasm caused by infection with the Human T-cell Lymphotropic Virus Type 1 (HTLV-1). Cardiac involvement in patients with ATLL is infrequent, and when it happens it is usually seen in aggressive ATLL subtypes. However, ATLL presenting as isolated cardiac valve involvement is extremely rare. To date, only three histologically proven cases of ATLL with isolated cardiac valve involvement have been reported. Herein, we describe a 61-year-old Peruvian man who presented heart failure symptoms secondary to progressive cardiac valve infiltration. The patient underwent mitral valve replacement with a mechanical prosthesis. Histopathological evaluation of the resected valve revealed leaflet thickening with a nodular appearance due to fibrous tissue containing atypical T-lymphocytes with Foxp3 expression, infiltrating all layers of the resected valve. Interestingly, tumor cells were distributed around an incidental venous malformation (i.e., cavernous hemangioma). Postoperative evaluation demonstrated positive serology for HTLV-1, and a diagnosis of ATLL was established. Postoperative positron emission tomography/computed tomography did not show lesions outside the heart and cell blood counts were within normal range with low level of circulating CD4+ CD25+ lymphoma cell counts (7%); therefore, patient's disease was considered as smoldering ATLL and a "watch and wait" strategy was pursued. Currently, the patient is alive with no progression of disease after 18 months from diagnosis. Isolated cardiac valve involvement by ATLL should be considered in the differential diagnosis of HTLV-1 carriers with progressive heart failure, even when systemic lymphoma involvement is absent or not apparent.

Cardiac Involvement of Adult T Cell Leukemia/Lymphoma

Adult T-cell leukemia/lymphoma (ATL) is a refractory T-cell lymphoma with variable clinical profiles, commonly exhibiting extra-nodal involvement. The myocardial involvement of ATL is often detected at an autopsy; however, the development of a symptomatic cardiac mass due to ATL is extremely rare. We herein report a 65-year-old man with ATL who developed cardiac symptoms due to a rapidly enlarging left ventricular mass soon after the initiation of systemic chemotherapy. We also summarize previously reported cases of symptomatic ATL with cardiac involvement.

Serous fluids and hematolymphoid disorders

Diagnosing hematolymphoid neoplasm by evaluating fine-needle aspiration (FNA) cytology sample is controversial and requires experience and clinical skills. This concept becomes more challenging when evaluating hematolymphoid neoplasm in body fluid. Differentiating between low-grade lymphoma and reactive lymphocytes is often difficult by morphology alone as reactive lymphoid cells may acquire activation morphology from being exposed to different cytokines within the body fluid. However, in most cases there are specific features that may aid in differentiating small reactive from non-reactive lymphocytes including the round shape of the nucleus, the absence of visible nucleoli and the presence of fine clumped chromatin. In large cell lymphoma and leukemia cells involvement of body fluid this concept becomes less challenging. Large cell lymphoma and leukemia cells tend to have large size nuclei, less mature chromatin, and visible nucleoli with and without cytoplasmic vacuoles. However, to reach accurate diagnosis and subclassification, the utilizing of flow cytometry, to confirm monoclonality, and other ancillary studies such immunocytochemistry, cytogenetics and molecular studies is needed. This review article will be incorporated finally as one of the chapters in CMAS (CytoJournal Monograph/Atlas Series) #2. It is modified slightly from the chapter by the initial authors in the first edition of Diagnostic Cytopathology of Serous Fluids.

Clinical features of cardiac lymphoma: an analysis of 37 cases

OBJECTIVE

To summarize the clinical and pathological features of patients with cardiac lymphoma.

METHODS

The general conditions, clinical features, pathological types, and prognostic indices of 37 patients with cardiac lymphoma treated in our hospital were analyzed.

RESULTS

Among the 37 patients, only one had primary cardiac lymphoma, and the other 36 patients had secondary cardiac lymphoma. The cardiac manifestations were mainly chest tightness, shortness of breath, increased heart rates, and electrocardiographic abnormality caused by pericardial effusion, but myocardial enzyme levels were normal in all patients. Only three patients displayed solid heart-occupying manifestations. These lesions were mainly located in the right atrium, and the masses were all larger than 5 cm. The pathological type was diffuse large B cell lymphoma that did not arise from the germinal center in all three patients.

CONCLUSIONS

Cardiac lymphoma was mostly secondary, and pericardial effusion was the primary objective sign. Moreover, cardiac lymphoma was characterized by a high international prognostic index, late stage, and high rates of T and NK cell lymphoma. Most cases were accompanied by serous cavity effusion, extranodal involvement of important organs, elevated lactate dehydrogenase levels, hypoalbuminemia, and normal myocardial enzyme levels.

Cytological Diagnosis of T Lymphoblastic Leukemia/Lymphoma in Patients with Pleural Effusion as an Initial Clinical Presentation: Two Case Reports of an Algorithmic Approach Using Complete Immunohistochemical Phenotyping

BACKGROUND

T cell lymphoblastic leukemia/lymphoma with the initial symptom of effusion is an uncommon condition. It may present a diagnostic challenge as lymphoblastic cells mimic normal lymphocytes under a low-power microscopic view.

CASES

Two cases are presented, both male, with the first aged 31 years and the second aged 54 years. Both initially presented with chest pain and shortness of breath, and CT scans found an anterior mediastinal mass and left pleural effusion in both subjects. Cytological smears of pleural fluid in each case showed monotonous small-to-medium-sized lymphoid cells with moderate chromatin condensation and round-to-convoluted nuclei. There were prominent apoptotic bodies and mitosis in both cases. Immunohistochemistry of cell blocks demonstrated their T cell lineage and lymphoblastic nature. Diagnosis of T cell lymphoblastic leukemia/lymphoma was determined by a 3-step algorithmic approach using complete panels of immunohistochemical markers (CD3, CD20, Ki-67, CD10, CD5, CD99, CD1a, CD34, CD4, CD8, TDT, CD7, CD2 and CD68).

CONCLUSION

An algorithmic approach based on cytological morphology and immunophenotyping is an effective way to diagnose T cell lymphoblastic leukemia/lymphoma in patients with an initial symptom of pleural effusion and insidious cytological morphology.