Small Intestinal Lymphomas and Alpha-chain Disease

Non-Hodgkin’s Lymphoma in Northern India: An Analysis of Clinical Features of 241 Cases

Background: Geographic variations with regard to incidence, clinical presentation, and histological subtypes are known to occur in several cancers. This study was aimed to see if similar differences existed in non-Hodgkin's lymphoma (NHL) also during pre-immunohistochemical era. Materials and Methods: Cases of NHL seen at Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi from January 1997 to December 2000, were analyzed for baseline clinical features and histology. Results: Total cases: 241, median age: 47 years (range 2–84 years), male-female ratio: 2.2:1, primary extranodal NHL: 44.2%, the most common histological subtype: Diffuse large cell (6.2% of the cases). Conclusion: Our patients presented at younger median age, had more male to female ratio, had diffuse large cell histology as the most common histological subtype.

Immunoproliferative Small Intestinal Disease Associated with Overwhelming Polymicrobial Gastrointestinal Infection with Transformation to Diffuse Large B-cell Lymphoma

Immunoproliferative small intestinal disease (IPSID) is an extra-nodal B-cell lymphoma most commonly described in the Mediterranean, Africa, and Asia. It is associated with poverty and poor sanitation, and is rarely encountered in developed countries. A 26-year-old previously healthy, Marshallese male was transferred to our facility with a 6-month history of watery diarrhea, weakness, and cachexia refractory to multiple short courses of oral antibiotics. Stool cultures grew Campylobacter jejuni and Vibrio fluvialis. Endoscopic evaluation showed histologic evidence of Helicobacter pylori gastritis and gross evidence of whipworm infection found in the colon. Mesenteric lymph node biopsy cultures grew Escherichia coli. Histopathology and immunohistochemical stains of the small intestine were consistent with IPSID. He subsequently transformed to diffuse large B-cell lymphoma (DLBCL) with tonsillar involvement despite treatment with rituximab and an extended course of antibiotics. Systemic chemotherapy with six cycles of rituximab, cyclophosphamide, vincristine, doxorubicin, prednisone, and lenalidomide, resulted in remission of his diffuse B cell lymphoma. This case is illustrative of IPSID developing in a previously healthy individual due to overwhelming polymicrobial gastrointestinal infection by C. jejuni and other enteric pathogens with subsequent transformation to an aggressive DLBCL. IPSID should be considered in residents of developing countries presenting with refractory chronic diarrhea, weight loss, and mesenteric lymphadenopathy.

Immunoproliferative small intestinal disease with protein loss complicated with duodenal T cell lymphoma during progression

A 52-year-old man was admitted to our hospital in October 2001 with abdominal pain. Abdominal X-ray indicated a diagnosis of ileus. Histopathological and immunological examination resulted in a diagnosis of immunoproliferative small intestinal disease (IPSID). He was treated with THP-COP therapy (pirarubicin, cyclophosphamide, vincristine, and prednisolone), which resulted in complete remission. Outpatient follow-up revealed hypoalbuminemia in May 2003 and upper gastrointestinal endoscopy showed duodenal mucosal nodularity. He was diagnosed with relapsed IPSID and salvage chemotherapy was started. Follow-up endoscopy confirmed that the therapy was effective, but uncovered another duodenal mucosal nodularity. Immunohistochemical staining revealed T-cell lymphoma. Chemotherapy was discontinued and the patient died in December 2004.

Infectious agents in mucosa-associated lymphoid tissue-type lymphomas: pathogenic role and therapeutic perspectives

Mucosa-associated lymphoid tissue (MALT) lymphoma probably constitutes the best in vivo model showing how complex interplay between B lymphocytes and the surrounding microenvironment may lead to a neoplastic disorder. After the seminal discovery of the pathogenic association between Helicobacter pylori and gastric MALT lymphomas, evidence suggests the possible involvement of other infectious agents in the development of MALT lymphomas arising at different body sites. Although several other bacteria (Borrelia burgdorferi, Campylobacter jejuni, and Chlamydia psittaci) and viruses (Hepatitis C virus) seem to play a role in lymphomas presenting at different locations, a possible common pathogenic mechanism is emerging. Several lines of evidence suggest that different infectious agents might provide a chronic antigenic stimulation that elicits host immune responses able to promote clonal B-cell expansion. This model is also substantiated by the increasing number of patients with MALT lymphomas who exhibit objective clinical responses after antimicrobial therapy. A multidisciplinary approach is critical to better understand the complex etiopathogenesis of MALT lymphomas with the final goal to dissect the clinicopathologic heterogeneity of these disorders and design more tailored preventive and therapeutic approaches.

A case report: isolated a heavy chain monoclonal gammopathy in a patient with polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin change syndrome

A 45-year-old South-Korean man presented with abdominal distension, progressive paresthesia and motor weakness of both lower extremities. Our case was identified as polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy and skin change (POEMS) syndrome based on diagnostic criteria. Circulating M components of POEMS syndrome consist mainly of IgG or IgA-lambda and rarely IgM-lambda, IgG-kappa or isolated light chains. In this case, the M-band on serum protein electrophoresis and isolated IgA heavy chain on serum immunofixation electrophoresis were demonstrated, but there was no abnormal light chain. We suggest that this case may be associated with a pattern of abnormal secretion of monoclonal protein or a coincidence of a heavy chain disease in POEMS syndrome, even though the latter possibility may be very rare.

Immunoproliferative small intestinal disease (IPSID): a model for mature B-cell neoplasms

Immunoproliferative small intestinal disease (IPSID) was recently added to the growing list of infectious pathogen-associated human lymphomas. Molecular and immunohistochemical studies demonstrated an association with Campylobacter jejuni. IPSID is a variant of the B-cell lymphoma of mucosa-associated lymphoid tissue (MALT), which involves mainly the proximal small intestine resulting in malabsorption, diarrhea, and abdominal pain. Geographically, IPSID is most prevalent in the Middle East and Africa. IPSID lymphomas reveal excessive plasma cell differentiation and produce truncated alpha heavy chain proteins lacking the light chains as well as the first constant domain. The corresponding mRNA lacks the variable heavy chain (V(H)) and the constant heavy chain 1 (C(H)1) sequences and contains deletions as well as insertions of unknown origin. The encoding gene sequence reveals a deletion of V region and parts of C(H)1 domain. Cytogenetic studies demonstrated clonal rearrangements involving predominantly the heavy and light chain genes, including t(9;14) translocation involving the PAX5 gene. Early-stage IPSID responds to antibiotics (30%-70% complete remission). Most untreated IPSID patients progress to lymphoplasmacytic and immunoblastic lymphoma invading the intestinal wall and mesenteric lymph nodes, and may metastasize to a distant organ. IPSID lymphoma shares clinical, morphologic, and molecular features with MALT lymphoma, lymphoplasmacytic lymphoma, and plasma cell neoplasms.

Small Bowel Lymphoma

Treatment of small bowel lymphoma requires the expertise of medical and surgical subspecialists. The two most important factors that determine the optimal treatment are histology and staging of small bowel lymphoma. Other factors that may affect treatment include age, multiple areas of involvement, tumor size, and perforation. At present, the best treatment for gastrointestinal lymphoma (stage IE disease) is limited resection of the tumor, followed by postoperative radiotherapy. The cure rate is approximately 75% for stage IE patients, even for those with aggressive histologic types. Chemotherapy is reserved for advanced-staged tumors. In patients with regional nodal involvement or extranodal involvement confined to one side of the diaphragm (pathologic stage IIE disease), chemotherapy should be combined with radiation therapy. The best chemotherapy regimen depends on the histology of the tumor. For diffuse large B-cell lymphoma, the most frequently diagnosed subtype of non-Hodgkin's lymphoma (NHL), the CHOP regimen (cyclophosphamide, doxorubicin, vincristine, and prednisone) is still the gold standard. Clinical trials have been conducted evaluating the new monoclonal antibody rituximab, along with the CHOP regimen for primary NHL. Results have been promising. The use of rituximab in the treatment of extranodal lymphoma is still being evaluated. Low-grade lymphomas have a more indolent course and do not respond as well to combination chemotherapy agents as the high-grade tumors. Fludarabine alone or in combination with cyclophosphamide is effective as a first-line agent for patients with low-grade NHL. It has also been used to treat relapsed or refractory low-grade NHL. Some promising results have been reported using the chemoimmunotherapy agent rituximab alone or in combination with fludarabine for the treatment of low-grade NHL. However, clinical trials are still needed. In patients with nodal involvement on both sides of the diaphragm or other extranodal involvement such as bone marrow or liver (pathologic stages IIIE and IVE), the disease is managed primarily with combination chemotherapy. Radiation therapy is reserved for treatment of initially bulky tumor sites, treatment of residual disease following chemotherapy, or serious local problems. The disease can be controlled in 25% to 40% of patients with stage IIIE or IVE disease. As with stage IIE disease, the optimal chemotherapy regimen depends on the histologic subtype of NHL.

Clinicopathological features of primary intestinal lymphoma in Taiwan: a study of 21 resected cases

In Taiwan, primary intestinal lymphomas (PIL) have rarely been reported and characterized. Using WHO classification, we retrospectively studied the clinicopathological features of PIL cases surgically resected in Taiwan. There were 21 cases, 14 males and seven females, with a median age of 66. The most common symptom at presentation was abdominal pain (n = 14; 66.7%). Six (28.6%) cases showed perforation and two (9.5%) intussusception. Two patients had multicentric tumors. The most common location was ileum (n = 11, 52.4%). Twenty cases (95.2%) were of B-cell lineage, and one (4.8%) was of T-cell lineage. These cases were classified as diffuse large B-cell lymphoma (DLBL) (n = 18; 85.7%), Burkitt lymphoma (n = 2; 9.5%), and enteropathy-type T-cell lymphoma (EATL) (n = 1; 4.8%). One case was lost to follow-up. The 1- and 2-yr survival rates of the remaining 20 patients were 44.4% and 26.7%, respectively. In conclusion, we describe the clinicopathological findings of a rare case of appendiceal DLBL and another one of ileal EATL, that have never been reported in Taiwan previously. We found that in Taiwan PIL occurred in the elderly, with a male predominance, showing a relatively aggressive clinical course, and a pattern similar to that seen in western countries, except for the absence of multiple lymphomatous polyposis.

Immunoproliferative small intestinal disease: prolonged 30-year course without development of lymphoma

Immunoproliferative small intestinal disease (IPSID) is mostly found in young adults of low socioeconomic class in developing countries. This condition is characterized by a dense lymphoplasmacytic infiltrate beneath the epithelium in the duodenal and proximal jejunal mucosa and in the mesenteric lymph nodes. In two thirds of cases, the involved lymphocytes elaborate an anomalous alpha-heavy chain protein. The etiology of this disease is unclear, although various parasitic, genetic, and toxic mechanisms have been proposed. Half of all IPSID patients will be found at diagnosis to have a concurrent intestinal B-cell lymphoma, and most of the remaining patients develop frank lymphoma within a few years. Although most reports of IPSID are from developing nations or indigent immigrant populations within Western countries, four cases of an IPSID-like condition have been documented in white women. Furthermore, although many IPSID patients progress to high grade indeterminate-type lymphoma within a few years of initial presentation, there have been occasional reports of long term survival without lymphomatous conversion. Here, we present an atypical case of IPSID--a California native who, though of Mexican heritage, had resided in the United States his entire life and did not belong to an indigent population. This patient had biopsy-proven IPSID that progressed over 30 yr but never exhibited lymphomatous conversion despite end stage intestinal stasis and recurrent obstruction, culminating in death. Our case calls into question some current assumptions about the prelymphomatous nature of this disease.

Alpha-heavy chain disease, Mediterranean lymphoma, and immunoproliferative small intestinal disease: a review of clinicopathological features, pathogenesis, and differential diagnosis

There are a number of clinical syndromes associated with chronic diarrhea, malabsorption, and lymphoplasmacytic proliferation of the small intestine. In Middle-Eastern and Mediterranean countries immunoproliferative small intestinal disease is endemic, whereas in other parts of the world (including Northwestern Europe and North America) celiac sprue, and other sprue-like syndromes refractory to dietary gluten withdrawal, predominate. All of these syndromes appear to involve chronic stimulation of intestinal mucosa-associated lymphoid tissue and are associated with a heightened risk of malignant transformation. The clinicopathological features of these diseases, and distinction of the Middle Eastern syndromes from those more common in the Western hemisphere, have been reviewed.

Primary pancreatic lymphoma associated with short bowel syndrome: review of carcinogenesis of gastrointestinal malignancies

We describe a case of stage IE diffuse small cleaved B-cell lymphoma involving primarily the head of pancreas in a patient with chronic malabsorption as a result of short bowel syndrome. The association of chronic malabsorption with lymphoma and other cancer is reviewed. The possible role of dietary fat as an etiologic link to this association is speculated.

Malignant lymphoma in coeliac disease: various manifestations with distinct symptomatology and prognosis?

OBJECTIVES

To study the different forms of malignant lymphoma complicating coeliac disease in a low-prevalence area, according to extranodal-nodal and extraintestinal-intestinal manifestations.

SUBJECTS AND SETTING

Patients recruited from two University Hospitals (Amsterdam, Leiden) and from PALGA (National Dutch data-bank) over a 16-year period.

DESIGN

Review of hospital charts with respect to clinical presentation and treatment of both coeliac disease and malignant lymphoma. Re-evaluation of morphology and staging by immunoperoxidase, enzyme- and immunohistochemical stainings on unstained and frozen materials.

MAIN OUTCOME MEASURES

Clinical behaviour and T- or B-cell morphology of extranodal intestinal, extranodal extraintestinal and nodal intestinal disease.

RESULTS

Fourteen cases of enteropathy-associated lymphoma could be traced, 10 with a history of coeliac disease, four primarily presenting with malignant lymphoma. The usual extranodal intestinal lymphoma (eight cases) presented with abdominal pain, weight loss, and malabsorption. Six had atypical disease: four presented with extranodal extraintestinal disease, located in the skin or the respiratory tract; two patients had intractable malabsorption and oedema caused by a nodal intestinal lymphoma. Re-evaluation with additional immunohistochemical stainings in 11 patients showed a pleomorphic malignant infiltrate of histiocyte-like cells of T-cell origin, with a pattern of CD3+; CD4-; CD5 +/-; CD7+ and CD8-. It also established a more appropriate diagnosis in four, an 0.6-year earlier diagnosis in six, and an upgraded stage of disease in two patients. A more extensive spread and poorer outcome appeared to become more probable in the ranking order of extranodal intestinal, extranodal extraintestinal and nodal intestinal lymphoma.

CONCLUSIONS

A proper and timely diagnosis of enteropathy-associated lymphoma requires clinical vigilance and unrelentless perseverance to obtain adequate fresh and frozen tissue for histochemical staining. Further research in a larger number of patients is warranted to investigate the relation between the primary site of the lymphoma, i.e. extranodal intestinal, extranodal extraintestinal, or nodal intestinal, and (its impact on) clinical presentation and prognosis.

Malignant tumours of the small bowel

Early diagnosis of small intestinal cancers provides the best probability of cure. The astute clinician will include these tumours in the differential diagnosis when vague or non-specific abdominal complaints occur and a more common cause is not discovered. Failure to evaluate the small bowel, which is a blind spot to routine endoscopic and radiological diagnostic tests, constitutes a common error when confronted with occult gastrointestinal blood loss and normal upper and lower gastrointestinal examination. Surgical resection remains the cornerstone of therapy for these malignancies. Advances in effective chemotherapy for large bowel carcinoma may have an impact on the management of small intestinal adenocarcinomas. Substantial palliation can be offered to the patient with metastatic carcinoid tumour, but the long-term outlook for these patients remains poor. Early stage lymphomas of the intestine are readily treated by combined modality therapy while advanced stage disease remains resistant to curative management. The patient prognosis for a small bowel sarcoma is largely dependent on the tumour grade. A high index of suspicion to improve tumour detection and better treatments of tumours with the same histology at other anatomic sites should enhance the management and outcome of patients with small intestinal malignancies.

Extensive small intestinal T-cell lymphoma of low-grade malignancy associated with a new chromosomal translocation

BACKGROUND

Primary T-cell lymphoma of the small intestine is rare, and most cases have proved rapidly fatal.

METHODS

We describe a case of lymphoma involving the small intestine uniformly and extensively in a 28-year-old man on initial examination seen with long-standing diarrhea, malabsorption, and recurrent episodes of intestinal obstruction. Clinical remission was obtained with pentostatin (2'-deoxycoformycin, supplied by Professor Catovsky, London UK) after the patient had failed to improve under conventional chemotherapy. Tumor specimens as well as mesenteric lymph node, liver, and bone marrow specimens were studied with conventional pathology and immunochemistry. Additionally, mesenteric lymph nodes and peripheral blood cells were studied for T-cell receptor (TCR) gene rearrangement and karyotype.

RESULTS

Lymphoma cells were small T-lymphocytes with irregular pleomorphic nuclei, bearing the CD3, CD4 and TCR alpha-beta phenotype. Peripheral-blood cytology and bone marrow biopsy were normal. Southern blot analysis of the TCR beta-chain gene revealed the same monoclonal rearrangement in the mesenteric lymph nodes and peripheral blood lymphocytes. An as yet undescribed t(4;16)(q26;p13) translocation, involving the region where the interleukin-2 (IL-2) gene has been mapped, was present in the mesenteric lymph nodes and peripheral blood lymphocytes.

CONCLUSION

We believe this is the first description of an extensive, small intestinal lymphoma of low-grade malignancy made up of monoclonal T-cells with a TCR alpha-beta and helper/inducer phenotype, associated with a novel chromosomal translocation.

Immunoproliferative small intestinal disease: Mediterranean lymphoma and alpha heavy chain disease

Gastrointestinal lymphoma, uncommon in the West, is far more prevalent in developing countries where it falls into two groups: 'Western'-type lymphomas, similar to those seen in developed countries, and the so-called Mediterranean-type lymphoma. It is now accepted that Mediterranean lymphoma represents, in the majority if not in all cases, the late stage of alpha heavy chain disease (alpha-HCD). This disease is characterized by abnormal secretion of an immunoglobulin fragment; alpha-HCD and Mediterranean lymphoma constitute two ends of a spectrum of pathology now classified as immunoproliferative small intestinal disease (IPSID). IPSID is associated predominantly with poor socioeconomic conditions; patients present with progressive malabsorption in the second and third decades of life. Diagnosis is established by small bowel biopsy, with or without high serum levels of the alpha heavy chain protein. Treatment consists of an initial staging laparotomy, with debulking of lymphomatous deposits if appropriate, followed by chemotherapy or radiotherapy. Overall prognosis is poor but the recent use of doxorubicin-based chemotherapy offers some hope for the future.

Leukemic manifestation in a case of alpha-chain disease with multiple polypoid intestinal lymphocytic lymphoma

We describe a female aborigine from Taiwan with alpha-chain disease associated with multiple polypoid intestinal lymphocytic lymphoma and leukemic manifestation. Initially, the patient experienced intermittent diarrhea, abdominal pain, and leukemic manifestation. No evidence of bone marrow involvement was found. Alpha-chain protein was demonstrated in the serum. Gastroendoscopy and a series of radiographs of the small intestine revealed multiple polypoid tumors involving the entire length of the small intestine. Duodenal biopsy showed diffuse lymphocytic lymphoma. Immunohistochemical staining of tumor samples revealed features typical of alpha-chain disease. Cytogenetic analysis showed the same abnormal karyotypes of neoplastic clones in intestinal tumor cells and in circulating leukemic cells. The data suggest that alpha-chain disease can present initially with intestinal multiple polypoid lymphocytic lymphoma and leukemic manifestation without evidence of bone marrow involvement. The data also support the homing theory of lymphomas from mucosa-associated lymphoid tissue.

T-lymphoblastic lymphoma arising in the small intestine

The authors report the clinical, pathological and immunological features of a case of T-lymphoblastic lymphoma presenting with protein-losing enteropathy. There was extensive multifocal involvement of the duodenum, jejunum and ileum. The mediastinum was not enlarged; the peripheral blood picture and bilateral bone marrow trephine biopsies were unremarkable. The tumor cells were positive for terminal deoxynucleotide transferase, CD3, CD2, CD7 and CD10; they were negative for CD1, CD5, CD4, CD8 and HLA-DR. The immunophenotype was that of an immature thymic T-cell. Monocytic and B-cell markers were negative. Despite initial dose reduction in chemotherapy, the patient still developed massive intestinal hemorrhage and succumbed 2 wks after treatment. Postmortem examination confirmed absence of thymic involvement. The overall picture strongly suggests a primary intestinal origin of this T-lymphoblastic lymphoma which contradicts the conventional wisdom that T-lymphoblastic lymphoma arises in the thymus from primitive cortical lymphocytes before rapidly disseminating.

Plasma postheparin diamine oxidase in patients with small intestinal lymphoma

Diamine oxidase (DAO) is an enzyme located almost exclusively in villus tip enterocytes. Its plasma activity is enhanced by intravenous heparin which releases the enzymes from small bowel enterocytes into the blood. Plasma postheparin DAO (PHD) values have been shown to be significantly lower in patients with malabsorption and villous atrophy, thus suggesting that PHD reflects the mature enterocytic mass. In this study we have assayed PHD in five patients with small bowel lymphoma (two with immunoproliferative small intestinal disease [IPSID] and three with non-IPSID lymphoma) associated with malabsorption syndrome and small bowel mucosa atrophy. The PHD test was performed at diagnosis, after partial or complete remission induced by chemotherapy, and during the follow-up. The PHD values, very low at diagnosis (0.66 +/- 0.12 U/ml), increased during chemotherapy and reached the normal range (greater than 3.7 U/ml) when complete remission occurred. The PHD values rapidly and consistently decreased whenever the disease relapsed. Our data indicate that in patients with small bowel lymphoma PHD test is a sensitive marker of small bowel mucosa damage and suggest that it could be useful in monitoring the recovery of mucosal lesions induced by chemotherapy.

Gastrointestinal lymphoma

Primary GI lymphoma is a rare clinical entity. A primary nodal tumor should be ruled out. Symptoms may not be localizing and B symptoms are less common. A tissue diagnosis, preferably by transmural biopsy for small intestinal involvement, often reveals a high-grade morphology. The staging work-up should include a bone marrow examination, although formal staging laparatomy is not always required. Patients with Mushoff stage IE or IIE1 disease do better than those with extraregional nodal disease or distant metastatic involvement. Surgical resection with clear margins is required in order to maximize the changes for cure. Chemotherapy or radiotherapy may give a survival advantage when used as adjuvant treatment for selected stage IE and IIE disease. Chemotherapy should be used after surgical debulking in more advanced disease in order to minimize the chance for bleeding or performation. Future randomized, multi-institutional trials will give more direction as to the best modes of management.

Immunoproliferative small intestinal disease: portrait of a potentially preventable cancer from the Third World

PURPOSE

To review the recent progress in the understanding of clinical and laboratory characterization as well as management of immunoproliferative small intestinal disease (IPSID).

DATA IDENTIFICATION

A literature search was conducted using Index Medicus, MEDLINE (1962 to 1989), and bibliographies of identified relevant articles.

STUDY SELECTION

All international comprehensive reviews, reported epidemiologic or immunologic studies, and prospective clinical trials published or abstracted in English were selected.

RESULTS OF DATA SYNTHESIS

A high incidence of lymphoma primarily in the gastro-intestinal tract in Third World countries has stimulated enormous epidemiologic and pathogenetic interests globally. IPSID, with a distinctive biologic marker (alpha heavy chain para-protein), affects the young underprivileged population of those countries. The initially benign-appearing antibiotic-responsive immunoproliferative lesions often evolve to fatal high-grade lymphomas. Roles of environmental and host factors in this evolutionary course are emerging. Recently demonstrated malignant potentials form the early onset of pathogenesis have given a new dimension to the traditional management strategy of IPSID.

CONCLUSIONS

Epidemiologic, immunologic, and pathogenetic data that have emerged over the last 25-year study of IPSID have improved our understanding about the complexity of infection-immunity-cancer interrelationships, comparable to those that have arisen from the study of the acquired immunodeficiency syndrome. Early detection and institution of antimicrobial-based treatment regimens with judicious and consistent follow-up can save the lives of many young patients whose manpower is badly needed in Third World countries.

Immunoproliferative small intestinal disease: a study of 13 cases with alpha heavy-chain disease

The pathology of 13 cases of immunoproliferative small intestinal disease (IPSID) associated with alpha-heavy-chain disease--one an apparent non-secretor and another with localized infiltration--is described. Four cases exhibited immunohistological light-chain monotypia. In one of these, evolution of a light-chain negative cell population was observed over a 7-year period. In the intestine, centrocyte-like cells produced lympho-epithelial lesions in 11 cases and enlarged lymphoid follicles in three. In lymph nodes, perifollicular infiltration was observed in 11 cases and abnormal follicles in six. Of three patients with high-grade lymphoma at presentation, one died untreated at 2 months, and two are alive at 34 and 91 months. Of 10 patients with low-grade disease at presentation, two died--one at 76 months, the other after transforming to high-grade lymphoma at 73 months. Eight patients with low-grade disease are alive, an average of 67 months after presentation. Four of five conservatively treated low-grade cases (including three in remission) showed evidence of monoclonality at presentation (light-chain monotypia in two and gene rearrangement in two), while two of the five exhibited DNA aneuploidy. It is concluded that IPSID with alpha-heavy-chain disease is neoplastic in all its stages and is a variant of mucosa-associated lymphoma. The role of centrocyte-like cells and the response to conservative therapy are discussed.

Genomic alterations in a case of alpha heavy chain disease leading to the generation of composite exons from the JH region

Human alpha heavy chain disease (HCD) is characterized by the presence in patient's serum of a short Ig alpha chain devoid of light chains. We analyzed the serum protein, the alpha HCD mRNA and the productive rearranged H chain gene from the leukemic cells of a new case (YAO) of alpha HCD. The abnormal YAO alpha 1 Ig was devoid of VH and CH1 domains and started at the beginning of the hinge region. The alpha HCD mRNA was shorter than normal alpha mRNA and the cDNA prepared from YAO mRNA encoded a leader sequence, an insert of 70 nucleotides and the CH2 and CH3 exons. The origin of the inserted sequence was assessed by cloning and sequence analysis of the alpha 1 productive gene. It started with a leader exon, a leader-VH intron and the first 11 bp of a VH exon. Then the VH region was deleted and replaced by a 19-nucleotide sequence that turned out to correspond to the 3' part of a modified JH5 exon. It was followed by a 221-bp sequence homologous to the JH5-psi JH3 intron and by an inserted sequence of unknown origin. The 3' part of this insertion and the remnant of a JH6 exon delineated a third exon that was followed by a relatively conserved JH6-C alpha intron. These two composite exons were flanked by splicing sites and accounted for the 70-nucleotide insert of the cDNA. The genomic nucleotide sequence also revealed a large deletion in the switch CH1 region which eliminated normal splicing sites and resulted in splicing of the third exon directly to the CH2 exon.

Treatment of alpha chain disease. Results of a prospective study in 21 Tunisian patients by the Tunisian-French intestinal Lymphoma Study Group

Between 1981 and 1985, the authors studied 21 Tunisian patients with alpha chain disease. Twenty of 21 underwent laparotomy. According to Galian et al. six patients were classified Stage A, two Stage B, and 13 Stage C. The therapeutic regimen included the following: (1) Antibiotics: In the case of intestinal bacterial overgrowth (IBO), antibiotics selected by their antibiograms were delivered; in absence of IBO, metronidazole plus ampicillin were first given. The antibiotic treatment was changed in case of therapeutic failure. (2) Chemotherapy: From 1981 to 1983 a cyclophosphamide, Adriamycin (doxorubicin), teniposide (VM-26), prednisone (CHVP) protocol (Adriamycin 35 mg/m2, teniposide 50 mg/m2 day 2, cyclophosphamide 300 mg/m2 days 2 through 4, prednisone 40 mg/m2 days 1 through 10) was used. After 1983 bleomycin 15 mg, Adriamycin 30 mg, vinblastine 10 mg were given on day 15. Serum immunoelectrophoresis and immunohistochemical study of duodenojejunal specimens were made on a 3-month and 6-month basis, respectively. Survival curve analysis was made according to Kaplan and Meier. Results were as follows: (1) Stage A: Six patients were first treated by antibiotics alone; two complete responses (CR) persisting 42 and 55 months later were observed, respectively. The four antibiotic failures were submitted to further chemotherapy with four subsequent failures and two deaths. (2) Stage B-C: Chemotherapy led to nine CR with one precocious relapse, a salvage chemotherapy allowing to one more CR. (3) All stages mixed, percentage of survival reached 90 +/- 12% at 2 years and 67 +/- 25% at 3 years, all patients alive beyond 3.5 years being disease-free.

A new form of alpha-chain disease with generalized lymph node involvement

An autopsy case of alpha-chain disease (ACD) clinically manifesting generalized lymph node swelling, slight splenomegaly and long-standing ichthyosiform skin eruptions, was reported. Autopsy revealed systemic superficial and profound lymph node swelling and slight splenomegaly, but little or no tumorous lesion in any part of the alimentary tract or pulmonary tissue. The histologic picture of the lymph nodes showed a diffuse monomorphic plasmocytic lymphoma, and there was tumor cell infiltration in the spleen and bone marrow. Immunohistochemistry demonstrated that the tumor cells contained IgA devoid of light chains, i.e. ACD protein. Immunoelectron microscopy revealed that this abnormal immunoglobulin was localized in the rough endoplasmic reticulum and perinuclear space. Persistent chronic inflammation with infiltration mainly of helper-inducer T cells were found in the skin and dermatopathic lymphadenopathy was confirmed in the lymph node biopsies. From these peculiar clinicopathological features, this case is considered to be a previously unknown form of ACD.

Colonic involvement in angioimmunoblastic lymphadenopathy resembling inflammatory bowel disease

A woman 68 years of age had fever, malaise, diffuse lymphadenopathy, splenomegaly followed by abdominal pain, and diarrhea. A lymph node biopsy specimen showed nonspecific follicular hyperplasia. Symptoms were responsive initially to prednisone. Recurrent symptoms warranted colonic biopsy, which was consistent with Crohn's disease, and were responsive partially to prednisone and azulfidine. Because of progressive deterioration, a repeat lymph node biopsy was performed and showed the characteristic histologic feature of angioimmunoblastic lymphadenopathy (AILD). The evolution of the histopathologic features of the case is discussed, and gastrointestinal (GI) manifestations of AILD are reviewed. Although the GI tract is an unusual site for extra nodal AILD, colonic involvement can imitate the clinical and histologic features of inflammatory bowel disease.

Results of laparotomy in immunoproliferative small intestinal disease

Immunoproliferative small intestinal diseases (IPSID), previously known as Mediterranean Lymphomas, constitute more than 60% of the non-Burkitt's small intestinal lymphomas in Tunisia. A multidisciplinary study of IPSID was undertaken by the Tunisian/French Lymphoma Study Group in 1980 to reach a better understanding of the two subgroups of the disease: secreting IPSID (essentially alpha-chain disease [ACD]); and nonsecreting IPSID (NS-IPSID) (extensive small intestinal lymphomas without gammopathy). The results of initial exploratory laparotomy performed in 38 cases of IPSID (17 ACD and 21 NS-IPSID) are described here, and show notable similarities between the two groups: the extensive pattern of the abnormal cell infiltrate along the major part of the small intestine; frequent and extensive involvement of the mesenteric lymph nodes; the existence of several degrees of severity in small intestinal mesenteric lymph nodes; and other intraabdominal organ involvement. Certain differences also were observed: the relatively high degree of tropism of the NS-IPSID towards the gastric mucosa which was absent in the ACD of this series; and the more frequent involvement of the entire length of the small bowel in ACD. In spite of these discrete differences, the IPSID form a homogeneous group which is definitely distinguishable from the segmentary small intestinal lymphomas known as Western-type, and which account for approximately one third of our non-Burkitt's small bowel lymphomas.

Immunology of gastrointestinal lymphoma

Experimental work showing that IgA plasma cell precursors activated in gut associated lymphoid tissue (GALT) of rats and sheep migrate to the lamina propria of the gut via the regional lymphatics, mesenteric lymph node and blood, has been supported by immunohistochemical studies. In rats, immunoblasts with cytoplasmic IgA are present in the Peyer's patches in association with the high endothelial venules which is probably an important, though not the only, site of extravasation into the gut, whereas cells with cytoplasmic IgA are rarely observed in the dome regions of Peyer's patches. Immunohistochemical studies of human Peyer's patches have revealed differences between the distribution of cells with cytoplasmic IgA in man compared to rats. In man, immunoblasts with cytoplasmic IgA are not concentrated in the zone of cells containing the high endothelial venules, whereas they are present in the dome regions of the Peyer's patches. The following questions arise: Do precursors of IgA plasma cells activated in human GALT migrate to the lamina propria via the blood, but extravasate predominantly via the capillary network, rather than the high endothelial venules? or do IgA plasma cell precursors 'mature' in situ in the Peyer's patches of man and subsequently migrate laterally to seed the lamina propria? Three lines of evidence from studies of primary B cell lymphomas of GALT support the latter hypothesis: 1) Primary B cell lymphomas of the gut remain localized to GALT for long periods of time; 2) Histological studies of the lymphoid tissue in these lymphomas have shown a gradation of cell types, from the muscularis mucosae towards the mucosal epithelium, which strongly suggests that plasma cells develop in situ in the gut from the adjacent layers of cells; 3) Preliminary studies of DNA extracted from the blood-borne cells from patients with GALT-derived B cell lymphoma have failed to demonstrate the presence of clonal gene rearrangements. Normal and malignant human GALT contains a perifollicular population of B cells with centrocyte-like morphology which lack surface IgD. No direct equivalent can be detected in rodent Peyer's patches. Their quiescent nature and distribution in malignant GALT suggests that they are follicle centre cell-derived and precursors of immunoblasts and plasma cells. As such they may be memory B cells. Their association with epithelium is a consistent feature of normal and malignant GALT which is of unknown but undoubted significance. The function of intraepithelial T cells is still unknown. Malignant T cells in MHI may be derived from intraepithelial T cells.(ABSTRACT TRUNCATED AT 400 WORDS)

Alpha-chain disease. Report of a case from Taiwan

The occurrence of alpha-chain disease (alpha-CD) in a Chinese patient, a resident of Taiwan, is reported. The patient's clinical features were characterized by severe malabsorption and ran a rapidly deteriorated course. Duodenal biopsy showed total villous atrophy with a heavy infiltration of the lamina propria by lymphoplasmacytic cells. Colonic biopsy revealed immunoblastic lymphoma. alpha-CD protein was demonstrated in the patient's serum and concentrated urine by the immunoselection method, and also detected in the cellular infiltrate by immunoperoxidase technique. Postmortem examination disclosed that the lymphoma involved not only the entire gastrointestinal tract and mesenteric nodes, but also the retroperitoneal and peripheral lymph nodes. Immunoperoxidase studies support the concept of a common clonal origin of the lymphoplasmacytic proliferation and immunoblastic lymphoma in alpha-CD.

Gastric form of alpha chain disease

A case of alpha chain disease, involving the stomach only, is reported in an Algerian man suffering from epigastric pains. Upper digestive tract fibreoptic endoscopy showed two antral ulcers and an ulcerative gastritis pattern, which promptly disappeared with cimetidine treatment. Antral biopsies at a distance from the ulcers, but not of the ulcer crater itself, disclosed a dense infiltration of antral lamina propria by mature or sometimes atypical plasma cells. On transmural surgical antral biopsy, the infiltrate spread to the superficial part of the submucosa. No other localisation of the disease was found in spite of multiple biopsies obtained by endoscopy, with a peroral capsule and during staging laparotomy. The alpha chain disease protein was absent from serum and urine, but found in the gastric juice and in the cytoplasma of the cellular infiltrate (alpha 1 subclass). A complete clinical, endoscopic, histological and immunological remission was observed after a six months' course of oral tetracycline.

Primary lymphomas of the small intestine: east-west contrast

Primary small intestinal lymphoma (PSIL) represents a heterogenous group of disorders with variable clinical and pathologic features and a characteristic age, socioeconomic, and geographic distribution. In developed countries, PSIL usually occurs as a localized ileal tumor, shows a bimodal age distribution, and most frequently presents with abdominal pain and obstructive symptoms. Histologically, most of these tumors are diffuse histiocytic, lymphocytic, or undifferentiated lymphomas. Other variants of PSIL, collectively referred to as immunoproliferative small intestinal disease, occur most often among young patients of poor socioeconomic status in Third World countries, mostly in the Middle East and Mediterranean area. They are characterized by involvement of long loops of the upper small intestine and commonly present with abdominal pain, diarrhea, malabsorption, and clubbing of the fingers. A subgroup of these patients shows a serological abnormality with the appearance of part of the alpha heavy chain of IgA in the serum. Histologically, the lesion appears as a dense diffuse lymphoplasmacytic infiltrate of the mucosa of the upper jejenum or duodenum. A form of malignant lymphoma of true histiocytic origin complicates long-standing celiac disease. The contrasting clinical, epidemiological, histopathological, and immunological features of these variants of PSIL raise interesting questions about the pathogenesis of small bowel lymphoma.

Plasma cell infiltration of the small bowel: lack of evidence for a non-secretory form of alpha-heavy chain disease

Eight patients with diffuse plasma cell infiltration of the small bowel who had the clinical features of immunoproliferative small intestinal disease (IPSID), but whose serum was negative for free alpha-heavy chains, were investigated for evidence of a non-secretory form of alpha-chain disease (alpha-CD). Molecular sieving and immunoblotting of serum, immunoperoxidase staining of biopsy specimens, and in vitro protein synthesis studies utilising an immunoprecipitation technique and polyacrylamide gel electrophoresis, failed to detect any new cases of alpha-CD. Four of the eight cases were found to have diffuse intestinal lymphoma. The remaining four patients, who were unsuccessfully investigated for evidence of a significant abnormality in cellular immunity, have not developed detectable alpha-CD protein or lymphoma over a mean of 143 months. Despite continuing exposure to possible environmental stimuli, it is concluded that not all cases of IPSID elaborate detectable alpha-CD protein or evolve to lymphoma.

Light chains in Mediterranean lymphoma

Four cases of Mediterranean lymphoma, in two of which serum alpha chains had been identified, were investigated with immunohistochemical techniques. In addition to alpha chains of alpha 1, subclass, monotypic light chains were identified in infiltrating tumour cells in all four patients and in plasma cells in two. The pattern of staining was in keeping with loss of light chain occurring with plasma cell differentiation and strongly suggested that the plasma cells and tumour cells shared a common clonal origin. In two patients concentrations of dendritic reticulum cells were identified in the tumour. These results support the suggestion that Mediterranean lymphoma is a tumour of follicle centre cells which undergoes plasma cell differentiation as a result of exposure to lumenal antigen.