Transplacental transmission of natural-killer-cell lymphoma

Cross-individual cancer transmission to children during the gestational and perinatal periods

Cancer transmission may rarely occur between individuals. Besides through allogenic transplantation, cancer transmission via the hemochorial placenta, which is permissive for cell traffic, has been described in a few reports. Three etiologies of transplacental cancer transmission include (1) maternofetal transmission of maternal cancer cells, (2) transmission of gestational choriocarcinoma to the fetus, and (3) transfer of preleukemic cells from one monozygotic twin to the other. Additionally, we recently reported two pediatric cases of lung tumors in which the lung-only distribution of tumors and genomic profiling of both the child's and mother's tumor samples suggested the airway/transbronchial transmission of maternal cervical cancer cells to the child by aspiration at birth. The immune system coordinates the hemostatic balance between effector and regulatory immunity, especially during fetal development. The immunoregulatory properties are shared in both physiological pregnancy-related and pathological cancer-related conditions. Mechanistically, the survival and colonization of transmitted cancer cells within a child are likely attributed to a combination of the child's immune tolerance and the cancer's immune escape. In this review, we summarize the current understanding of gestational/perinatal cancer transmission and discuss the possible mechanism-based immunotherapy for this rare form of pediatric cancer.

Metastatic Lymphomas of the Placenta: A Literature Review With an Illustrative Case

Lymphoma is the fourth most common tumor to display placental metastasis. This study aimed to report a case of high-grade lymphoma involving the placenta and review the literature on lymphomas metastatic to the placenta. A systematic review was performed following the PRISMA guidelines, using the keywords "lymphoma" AND "placenta." All case reports and case series on lymphoma infiltrating the placenta were collected. Eight cases from 7 studies, including the present case, were synthesized. The mean patient age is 29.5 years. The clinical presentation is non-specific. Hematologic derangements included cytopenias or cytoses, and elevated prothrombin time. The mean gestational age (GA) when a diagnosis of lymphoma was rendered is 27 weeks. Five cases presented with either lymphadenopathy or visceral masses on imaging. Four of these cases eventually led to maternal demise. The mean GA when the fetus was delivered is 31 3/4 weeks. Grossly, most placentas had non-specific findings. Leukemic infiltrates were mostly seen within intervillous spaces. Intravillous infiltrates were associated with high-grade lymphomas, resulting in either maternal demise or stillborn fetuses. This study suggests that the placenta has mechanisms to guard against malignancies; however, these defense mechanisms are not foolproof and may be breached by tumor cells.

Chronic Myeloid Leukemia During Pregnancy with Placental Involvement: Case Report and Literature Review

Introduction: Chronic myeloid leukemia (CML) occurrence during pregnancy is unusual due to the low prevalence of the disease in women of childbearing age, with only three reported cases. Case report: The mother was diagnosed with CML with positive BCR-ABL gene fusion in her 32nd week of gestation. The placenta showed an increased population of myelocytes and segmented neutrophils in the intervillous space and features of maternal villous malperfusion (increased perivillous fibrinoid material and distal villous hypoplasia). The mother underwent leukapheresis and delivered the neonate at 33 wk gestation. The neonate demonstrated neither leukemia nor other pathology. The mother is in remission after four years of follow-up. Conclusion: Leukapheresis was performed safely during pregnancy and provided a safe management strategy until the delivery one week later.

Imaging evaluation of lymphoma in pregnancy with review of clinical assessment and treatment options

Lymphoma-related malignancies can be categorized as Hodgkin's lymphoma (HL) or non-Hodgkin's lymphoma (NHL) based on histologic characteristics. Although quite rare during pregnancy, HL and NHL are the fourth and fifth most common malignancies during the pregnancy period, respectively. Given the rarity of lymphoma among pregnant patients, radiologists are usually unfamiliar with the modifications required for staging and treatment of this population, even those who work at centers with busy obstetrical services. Therefore, this manuscript serves to not only review the abdominopelvic imaging features of lymphoma in pregnancy, but it also discusses topics including birthing parent and fetal lymphoma-related prognosis, both antenatal and postpartum, current concepts in the management of pregnancy-related lymphoma, as well as the current considerations regarding birthing parent onco-fertility.

Addressing microchimerism in pregnancy by ex vivo human placenta perfusion

The physical connection of mother and offspring during pregnancy allows the bi-directional exchange of a small number of cells through the placenta. These cells, which can persist long-term in the recipient individual are genetically foreign to it and therefore fulfill the principle of microchimerism. Over the last years, pioneer research on microchimeric cells revealed their role in immune adaptation during pregnancy and priming of tolerogenic responses in the progeny. However, the mechanisms involved in cell transfer across the placenta barrier remain poorly investigated. In this review, we summarize the evidence of fetomaternal microchimerism, propose a mechanism for cell trafficking through the placenta and discuss the different models and techniques available for its analysis. Likewise, we aim to generate interest in the use of ex vivo placenta perfusion to investigate microchimerism in physiological and pathological settings.

Chronic active Epstein-Barr virus-associated secondary hemophagocytic lymphohistiocytosis in pregnancy: a case report

BACKGROUND

Secondary hemophagocytic lymphohistiocytosis (sHLH) is a rare and fatal disease characterized by uncontrolled immune cell activation that can lead to a cytokine storm. Unfortunately, this condition can occur even during pregnancy, threatening both maternal and fetal lives.

CASE PRESENTATION

A 23-year-old nulliparous woman at 26 weeks of gestation presented with continuous fever, coughing, and sore throat. Upon arrival at our hospital, her temperature was >38°C and laboratory findings indicated cytopenia (neutrophil count, 779/μL; hemoglobin level, 10.2 g/dL; platelet count, 29,000/μL), elevated ferritin level (1,308 ng/mL), and elevated soluble interleukin-2 receptor level (11,200 U/mL). Computed tomography showed marked splenomegaly. Bone marrow examination revealed hemophagocytosis, and blood examination showed a plasma Epstein-Barr virus (EBV) DNA level of 8.9 × 10⁵ copies/μg. The monoclonal proliferation of EBV-infected T cells was confirmed by Southern blotting, and the patient was diagnosed with chronic active EBV-associated sHLH and T-cell lymphoproliferative disease. Immediately after admission, the patient's condition suddenly deteriorated. She developed shock and disseminated intravascular coagulation, requiring endotracheal intubation along with methylprednisolone pulse and etoposide therapy. Although the patient recovered, she delivered a stillborn baby. After delivery, she was treated with reduced-dose dexamethasone, etoposide, ifosfamide, and carboplatin (DeVIC) and steroid (dexamethasone), methotrexate, ifosfamide, L-asparaginase, and etoposide (SMILE) chemotherapies. Five months after diagnosis, she received human leukocyte antigen-haploidentical allogeneic bone marrow transplantation from her sister. She remains in remission for 5 months from the time of transplantation to the present.

CONCLUSIONS

sHLH, which may cause maternal and fetal death, should be carefully considered in critically ill pregnant women, particularly those presenting with continuous fever and cytopenia.

Hemophagocytic lymphohistiocytosis during pregnancy: a review of the literature in epidemiology, pathogenesis, diagnosis and treatment

Hemophagocytic lymphohistiocytosis during pregnancy is rare; it is often misdiagnosed, resulting in a high maternal and foetal mortality rate. Herein, based on limited case reports including antepartum and postpartum cases, we reviewed the current studies of pregnancy-related hemophagocytic lymphohistiocytosis, and compared the epidemiology, aetiology, diagnosis and treatment of pregnancy-related hemophagocytic lymphohistiocytosis with non-pregnancy, enriching the understanding of hemophagocytic lymphohistiocytosis and its treatment in obstetrics.

Placental pathology in cancer during pregnancy and after cancer treatment exposure

Cancer during pregnancy has been associated with (pathologically) small for gestational age offspring, especially after exposure to chemotherapy in utero. These infants are most likely growth restricted, but sonographic results are often lacking. In view of the paucity of data on underlying pathophysiological mechanisms, the objective was to summarize all studies investigating placental pathology related to cancer(treatment). A systematic search in PubMed/Medline, Embase (OVID) and SCOPUS was conducted to retrieve all studies about placental pathology in cancer during pregnancy or after cancer treatment, published until August 2020. The literature search yielded 5784 unique publications, of which 111 were eligible for inclusion. Among them, three groups of placental pathology were distinguished. First, various histopathologic changes including maternal vascular malperfusion have been reported in pregnancies complicated by cancer and after cancer treatment exposure, which were not specific to type of cancer(treatment). Second, cancer(treatment) has been associated with placental cellular pathology including increased oxidative damage and apoptosis, impaired angiogenesis and genotoxicity. Finally, involvement of the placenta by cancer cells has been described, involving both the intervillous space and rarely villous invasion, with such fetuses are at risk of having metastases. In conclusion, growth restriction is often observed in pregnancies complicated by cancer and its cause can be multifactorial. Placental histopathologic changes, cellular pathology and genotoxicity caused by the cancer(treatment) may each play a role.

Vaginal Transmission of Cancer from Mothers with Cervical Cancer to Infants

Two cases of pediatric lung cancer (in 23-month-old and 6-year-old boys) resulting from mother-to-infant transmission of uterine cervical tumors were incidentally detected during routine next-generation sequencing of paired samples of tumor and normal tissue. Spontaneous regression of some lesions in the first child and slow growth of the tumor mass in the second child suggested the existence of alloimmune responses against the transmitted tumors. Immune checkpoint inhibitor therapy with nivolumab led to a strong regression of all remaining tumors in the first child. (Funded by the Japan Agency for Medical Research and Development and others; TOP-GEAR UMIN Clinical Trials Registry number, UMIN000011141.).

Maternal Hematologic Neoplasms during Pregnancy: Histologic Findings in the Placenta

Placental metastasis of maternal neoplasms is well documented in solid tumors, unlike hematologic neoplasms. We reviewed placental findings from deliveries complicated by maternal hematologic neoplasms exploring the prevalence and patterns of placental transmission and insufficiency. In the 8-yr study period, 11 cases were analyzed. Acute myeloid leukemia was the most common diagnosis (4/11, 36%). Seven cases (63%) showed no evidence of placental spread of neoplasm, while four cases (36%) showed placental spread, restricted to the maternal compartment. Maternal vascular malperfusion was documented in 8/11 (72%) cases. Neonatal follow up was available in 10 cases, all children were alive and well.

Red blood cell transfusion and its alternatives in oncologic surgery-A critical evaluation

Although blood transfusions have been used for more than 100 years and their potential to save lives is indisputable, there is still limited data on medium- and long-term outcomes after hemotherapy. Until recently, red blood cell transfusions represented the most commonly employed treatment for cancer anemia. As transfusions have been related to worse patient outcome in oncologic surgery, preventive strategies and alternative treatment approaches in the perioperative setting are warranted. This review aims to evaluate the evidence concerning the impact of transfusion on the course of malignant diseases with a focus on oncologic surgery and to provide a bundle of measures to improve patient care. The perioperative period is pivotal in determining long-term cancer outcome. An increasingly recognized area for improvement during this highly sensitive period is the treatment of anemia for three main reasons: Firstly, anemia has been recognized as an independent predictor of poor prognosis in cancer patients. Secondly, anemia is largely undertreated. Thirdly and probably most importantly, anemia therapy relied and often still relies heavily on red blood cell (RBC) transfusions, which may be an often suboptimal stopgap treatment. Perioperative RBC transfusions should be kept to a minimum due to growing concerns regarding the associated risks, which this review tries to clarify by providing an update of recent literature. This review furthermore discusses treatments for anemia and provides best-practice approaches to improve perioperative management of oncology patients undergoing surgery.

Natural killer/T-cell lymphoma and secondary haemophagocytic lymphohistiocytosis in pregnancy

Haemophagocytic lymphohistiocytosis (HLH) is a rare and potentially fatal disorder. It is challenging to diagnose due to its rarity and variation in clinical presentation, laboratory abnormalities and underlying aetiologies. A reproductive-aged woman, gravida 2 para 1001 at 27 weeks gestation presented with fever, hypotension and subacute upper respiratory infection. She delivered a male infant by caesarean section secondary to fetal distress. Subsequently, she was diagnosed with T-cell lymphoma and secondary HLH. Despite management with supportive care and multiple chemotherapeutic agents, she ultimately died of multiorgan failure. Patients with HLH secondary to malignancy have a particularly poor prognosis. This case highlights the importance of considering secondary HLH in the differential diagnosis of a patient with fever, pancytopenia and systemic symptoms of unclear aetiology in pregnancy.

Breast carcinoma in pregnancy with spheroid-like placental metastases-a case report

Breast cancer is one of the most common malignancies diagnosed in pregnancy. Although the tumor is often detected at an advanced stage, placental metastases are rare. Here, we describe the case of a woman with breast cancer recurrence during pregnancy and subsequent metastases. The focus of this study is the large amount of placenta metastases, which have been analyzed immunohistochemically. Staining with trophoblast markers (placenta alkaline phosphatase, beta human chorionic gonadotropin and human placental lactogen) showed the strict localization of metastases in the intervillous space without invasion into fetal tissue. They have a large spheroidal shape and are free of blood vessels. Staining with Ki-67 revealed an outer proliferative shell and inner necrotic core. At week 28, a healthy newborn was born by elective cesarean section. A few weeks later, after surgery and FEC60 (fluorouracil, epirubicin, cyclophosphamide) cycles, the patient died. Breast cancer metastases in the placenta are rarely described. The special immunological environment in pregnancy may influence phenotype, growth, and behavior of tumor and metastases.

Cancer cell transmission via the placenta

Cancer cells have a parasitic propensity in the primary host but their capacity to transit between individuals is severely restrained by two factors: a lack of a route for viable cell transfer and immune recognition in allogeneic, secondary recipients. Several examples of transmissible animal cancers are now recognised. In humans, the only natural route for transmission is via the haemochorial placenta which is permissive for cell traffic. There are three special examples of this occurring in utero: maternal to foetus, intraplacental twin to twin leukaemias and choriocarcinoma-extra-embryonic cells to mother. We discuss the rare circumstances under which such transmission occurs.

Maternal microchimerism in health and disease

Circulating maternal cells transfer to the fetus during pregnancy, where they may integrate with the fetal immune and organ systems, creating a state of maternal microchimerism (MMc). MMc can persist throughout the child's life, and it has been implicated in the triggering or perpetuation of chronic inflammatory autoimmune diseases, in the context of specific major histocompatibility genes. Correlative data in humans have now been tested in animal model systems. Results suggest that maternal-fetal tolerance may have health implications far beyond the time of pregnancy and into the child's life.

Aggressive Breast Cancer during Pregnancy with a Rare Form of Metastasis in the Maternal Placenta

Breast cancer is the second most common cancer diagnosed during pregnancy. Here we describe a 29-year-old patient with a recurrence of breast cancer with simultaneous brain, pulmonary and placenta metastasis. An overview of the literature on placenta metastases is provided together with a report on the interdisciplinary medical management.

Obstetrical, fetal and postnatal effects of gestational antiblastic chemotherapy: how to counsel cancer patients

At least one in a thousand pregnancies is complicated by cancer and, as the maternal age at pregnancy increases, numbers are growing. If chemotherapy cannot be postponed, both doctors and patients face complex medical and ethical issues. There is a conflict between optimal maternal therapy and fetal wellbeing. Treatment during the first trimester increases the risk of congenital malformations, spontaneous abortions and fetal death. Second and third trimester exposure is less risky, but it can cause intrauterine growth retardation and low birth weight. Other effects on pregnancy after the first trimester include premature birth, stillbirth, impaired functional development, myocardial toxicity and myelosuppression. Counseling and management of these cases are difficult, because literature is mostly represented by case reports or retrospective series while randomized prospective studies or guidelines are lacking. Moreover, personal experience is often scanty due to the rarity of the condition. This article reviews the available data regarding the different aspects of systemic treatment of cancer during pregnancy to help oncologist and obstetricians in counseling their patients and treat them accordingly.

CD56-negative extranodal nasal type NK/T-cell lymphoma

Extranodal natural killer (NK)/T-cell lymphoma, nasal type, is a rare lymphoma that occurs predominantly in Asian adults. In this report, we describe the clinical and pathologic features of an unusual aggressive lymphoid neoplasm in a child and review the literature on NK/T-cell lymphoma in children. The patient was a 4-year-old Native American male with facial swelling, lymphadenopathy, and fevers. Biopsy demonstrated neoplastic lymphoid cells that expressed CD3, CD8, TIA-1, and EBV-encoded RNA without CD56. The patient failed multiagent chemotherapy and died of therapy-related complications. This case represents an extranodal NK/T-cell lymphoma, nasal type, with an unusual lack of CD56.

Immunologically silent cancer clone transmission from mother to offspring

Rare cases of possible materno-fetal transmission of cancer have been recorded over the past 100 years but evidence for a shared cancer clone has been very limited. We provide genetic evidence for mother to offspring transmission, in utero, of a leukemic cell clone. Maternal and infant cancer clones shared the same unique BCR-ABL1 genomic fusion sequence, indicating a shared, single-cell origin. Microsatellite markers in the infant cancer were all of maternal origin. Additionally, the infant, maternally-derived cancer cells had a major deletion on one copy of chromosome 6p that included deletion of HLA alleles that were not inherited by the infant (i.e., foreign to the infant), suggesting a possible mechanism for immune evasion.

Fetal cell microchimerism in human cancers

The transfer of fetal cells into the maternal circulation occurs normally during pregnancy and the post-partum persistence of these cells in the maternal blood and tissues, known as fetal cell microchimerism, has been clearly demonstrated. However, the long-term consequences of this phenomenon are only beginning to be appreciated. In particular, whether microchimerism could be involved in the carcinogenetic process or whether fetal microchimeric cells could be able to differentiate in host tissues, participating in the maternal response to injury, is still matter of study. In this review, the possible role and the consequences of fetal cell microchimerism, as emerged from studies in animal models and in women with different types of cancer, will be presented.

Donor-derived brain tumor following neural stem cell transplantation in an ataxia telangiectasia patient

BACKGROUND

Neural stem cells are currently being investigated as potential therapies for neurodegenerative diseases, stroke, and trauma. However, concerns have been raised over the safety of this experimental therapeutic approach, including, for example, whether there is the potential for tumors to develop from transplanted stem cells.

METHODS AND FINDINGS

A boy with ataxia telangiectasia (AT) was treated with intracerebellar and intrathecal injection of human fetal neural stem cells. Four years after the first treatment he was diagnosed with a multifocal brain tumor. The biopsied tumor was diagnosed as a glioneuronal neoplasm. We compared the tumor cells and the patient's peripheral blood cells by fluorescent in situ hybridization using X and Y chromosome probes, by PCR for the amelogenin gene X- and Y-specific alleles, by MassArray for the ATM patient specific mutation and for several SNPs, by PCR for polymorphic microsatellites, and by human leukocyte antigen (HLA) typing. Molecular and cytogenetic studies showed that the tumor was of nonhost origin suggesting it was derived from the transplanted neural stem cells. Microsatellite and HLA analysis demonstrated that the tumor is derived from at least two donors.

CONCLUSIONS

This is the first report of a human brain tumor complicating neural stem cell therapy. The findings here suggest that neuronal stem/progenitor cells may be involved in gliomagenesis and provide the first example of a donor-derived brain tumor. Further work is urgently needed to assess the safety of these therapies.

B-Cell Lymphoma During Pregnancy Associated with Hemophagocytic Syndrome and Placental Involvement

We report a case of B-cell lymphoma during pregnancy associated with hemophagocytic syndrome and placental involvement. A 33-year-old Japanese woman developed pancytopenia, hepatosplenomegaly, and a high-grade fever for 2 weeks at 23 weeks of gestation. The demonstration of hemophagocytes in her bone marrow confirmed the diagnosis of hemophagocytic syndrome. She was referred at 25 weeks of gestation for evaluation of hemophagocytic syndrome. The screening for infection and autoimmune disease was negative. Clinical manifestation suggested malignant lymphoma as the underlying cause of hemophagocytic syndrome, but we could not confirm any lymphoma involvement in the bone marrow aspiration. Glucocorticoid therapy did not arrest the hemophagocytic process. Her general status worsened, and reduction of amniotic fluid was noted. At 28 weeks of gestation, we performed a Cesarean section because of fetal distress. Microscopic examination of placental specimen revealed diffuse infiltration of large, atypical lymphoid cells involving the intervillous space. Using immunohistochemical study, we made the diagnosis of B-cell lymphoma. R-CHOP (rituximab/cyclophosphamide/doxorubicin/vincristine/prednisone) chemotherapy was administered on the eighth postpartum day. After 2 cycles of R-CHOP chemotherapy, hematopoiesis became normal and hepatosplenomegaly almost completely disappeared. After 6 cycles of R-CHOP, the patient received autologous peripheral-blood stem cell transplantation, and she is currently in complete remission 1 year after diagnosis. The infant did well, without clinical or laboratory manifestations of malignant lymphoma. In cases with suspected malignancy associated with hemophagocytic syndrome during pregnancy, it is important to verify placental microscopic examination for evaluating the causative disease of hemophagocytic syndrome.

Métastases placentaires de cancers maternels: revue de la littérature

The purpose of this paper was to update and analyse all the reported cases of placental metastasis. These tumours are rare and seem to complicate aggressive or disseminated malignant melanomas, leukaemias, breast cancers and lung cancers. Maternal prognosis is poor. The risk factors of cancer in the newborn are unknown. In a pregnant woman with a history of malignancy, a systematic histological examination of the placenta for evidence of metastasis is required. Close observation and follow-up of the infant has to be recommended, especially in case of placental involvement. To estimate the incidence of placental metastases and to improve knowledge of their natural history, the creation of registries of malignancies associated with pregnancy is required.

Do maternal cells trigger or perpetuate autoimmune diseases in children?

The placental barrier is not the impenetrable wall that it was once presumed to be. During pregnancy, fetal cells pass into the mother, where they persist for decades after the pregnancy, leading to fetal microchimerism (FMc). Maternal cells also pass into the fetus, where they can persist long after birth of the child into adulthood, leading to maternal microchimerism(MMc). FMc and MMc represent foreign cells, and thus have been implicated in the pathogenesis of autoimmune diseases that resemble graft-versus-host disease after stem cell transplantation. FMc, hypothesized to contribute to the high predisposition of autoimmune diseases in women, has been reviewed recently. In patients who have never been pregnant, (children, males, and nulliparous females), MMc may represent the foreign cells that initiate or perpetuate chronic inflammatory disease.

Hematologic Malignancies in Pregnancy

Hematologic malignancies complicating pregnancy are uncommon, but a delay in diagnosis or treatment can mean the difference between life and death. It is the responsibility of the obstetrician, nurse-midwife, or nurse practitioner to maintain a high index of suspicion when patients present with unexplained lymphadenopathy or protracted constitutional symptoms. Management of these patients requires a multifaceted team from the oncology, pediatrics, and obstetrics services. With most hematologic cancers now requiring multiagent chemotherapy for optimal survival, the patient, her family, and her physicians are often faced with what seems to be a Faustian dilemma. Most infants exposed in utero to multiagent chemotherapy, however, seem to suffer no long-term detrimental consequences.

[Surgery during pregnancy]

The decision for surgical intervention during pregnancy should be interdisciplinary and include all aspects of prenatal care. The risk of surgery to mother and fetus must be calculated and weighed against the disadvantages of other, nonradical methods. If there is no danger to the mother, the highest priority in all therapeutic considerations is the fetus and its development. The greatest threat to the fetus exists during the first trimester. In case surgery cannot be postponed till after birth, they should be done if possible during the 4th to 6th months of pregnancy, not the first trimester. In case of danger to the mother, necessary surgery must be performed any time during the pregnancy. Once extrauterine fetal survival is possible (the 24th or 25th week of pregnancy), danger to the mother and the child's mortality and morbidity of the various options must be carefully weighed for both premature delivery and continued pregnancy. Due to the problems of prematurity, any surgery during pregnancy should be carried out only in perinatal clinics outfitted with neonatologic intensive care units.

Possible roles and determinants of microchimerism in autoimmune and other disorders

Microchimerism is the presence of a low level of non-host stem cells or their progeny in an individual. The most common source of microchimerism is pregnancy. During pregnancy, bi-directional trafficking of hematopoietic cells occurs through the placenta and these microchimeric cells persist for decades after childbirth. A possible role of microchimerism in the pathogenesis of some (systemic sclerosis, systemic lupus erythematosus, primary biliary cirrhosis, autoimmune thyroid diseases and juvenile myositis) but not all autoimmune diseases has been suggested by recent studies. Contradictory reports exist regarding HLA allelic associations with persistent T lymphocyte microchimerism. Although much of the focus of past studies has been on microchimerism in the effector arm of the immune system, increasing evidence suggests that microchimeric cells may differentiate into many lineages in different tissues raising additional possible roles for these cells. The possibility of microchimerism in many organs should induce an exploration of how persistent mixtures of cells of different genetic backgrounds throughout the body may influence diverse physiologic processes during life. In the present review, we discuss possible influencing factors and roles of all forms of microchimerism in autoimmune and non-autoimmune diseases. A better understanding of the immune mechanisms, along with the identification of environmental and genetic risk factors, is crucial for further deciphering the many possible implications of maternal-fetal and fetal-maternal cell trafficking in health and disease.

Transplacental transmission of maternal B-cell lymphoma

We report a case of maternal malignant lymphoma transferred to the fetus during pregnancy. A 29-year-old woman developed lymphoma at 29 weeks' gestation, and her infant developed malignant lymphoma at 8 months. Immunohistochemical examinations revealed lymphoid cells of similar characteristics in the maternal, placental, and infant tissues.

Transplacental and other routes of cancer transmission between individuals

Cancer in pregnancy is not rare, and the possibility of transmission of malignancy from mother to child, while infrequent, represents a clinical challenge for the primary pediatric hematologist-oncologist. The authors summarize all reported cases of vertically transmitted cancer and review other reported cases of person-to-person transfer of malignancy. As these cases represent a unique physiologic model of tumor transplantation, the biology of cancer transmission is discussed and provisional guidelines are given for the screening of infants born to women with cancer.

Metastatic melanoma in pregnancy: risk of transplacental metastases in the infant

PURPOSE

Although metastases to the fetus via the placenta are rare, melanoma is the most common culprit. When it occurs, maternally derived melanoma metastasis in the infant is almost invariably fatal.

PATIENTS AND METHODS

This article reviews current guidelines for placental evaluation in pregnant women with metastatic melanoma and presents surveillance recommendations for their infants. Comprehensive literature reviews were performed on melanoma in pregnancy and melanoma metastasis to the placenta and fetus. The use of interferon alfa in the pediatric population was also reviewed. A comprehensive search of the MEDLINE database (1966 to 2002) was performed. Articles were reviewed and additional references were obtained from the bibliographies. Translation of non-English articles was performed, and authors of previous publications were contacted.

RESULTS

Eighty-seven patients with placental or fetal metastasis were identified. Twenty-seven occurrences were attributed to melanoma (31%). The fetus was affected in six of 27 melanoma patients (22%), with five of six infants dying of disease. The use of high-dose interferon alfa adjuvant therapy in pediatric patients has not been reported.

CONCLUSION

The placentas of women with known or suspected metastatic melanoma should be carefully examined grossly and histologically by pathologists. With placental involvement, fetal risk of melanoma metastasis is approximately 22%. Neonates delivered with concomitant placental involvement should be considered a high-risk population. The risk-benefit ratio of adjuvant treatment for a potentially affected infant should be carefully weighed.

Neonatal lymphocytes dominate against lymphocytes of their own mother but not against allogenic maternal or adult lymphocytes in bidirectional mixed lymphocyte cultures

OBJECTIVE

Recent studies have shown a regular prenatal transfer of maternal immunocompetent cells into the fetal circulation. However, these cells engraft and proliferate only in a few exceptional cases if the fetus reaches an immunocompetent state. Thus the fetus has to have an immunologic defense mechanism against the engraftment of maternal cells. In the current study we investigated whether the fetus has such an immune defense and whether this defense mechanism specifically attacks cells of the mother.

PATIENTS, MATERIAL AND METHODS

Blood samples were obtained from 15 mothers and 15 newborns directly after delivery. We compared individual vitality and spontaneous cytotoxicity between fetal and maternal lymphocytes in a cell ratio of 1:1 in nonstimulated bidirectional mixed lymphocyte cultures (MLC). The distribution of each cell population within the MLC was visualized by fluorescence in situ hybridization and X/Y-DNA probes. This was compared to MLCs between unrelated fetal and maternal as well as between unrelated adult lymphocytes.

RESULTS

After 72 h, a significant cell shift was observed only in the MLC with neonatal lymphocytes mixed with cells of their own mother; there was a significantly higher number of neonatal cells (0.71 vs. 0.29) present. All other groups continued to have a cell distribution of 1:1.

CONCLUSION

Our results show that neonatal lymphocytes specifically dominate against maternal but not allogenous maternal or adult lymphocytes in nonstimulated bidirectional MLCs.

Feto-maternal microchimerism in connective tissue diseases

Fetal progenitor cells traffic to the mother during pregnancy and can persist in the maternal circulation for many years. Feto-maternal microchimerism has been reported in women with scleroderma, but its contribution to the disease pathogenesis remains unclear. Furthermore, the involvement of microchimerism in other connective tissue diseases is controversial. We studied 243 females, 122 of whom had previously carried a male fetus (50 healthy controls, 23 patients with scleroderma, and 49 with other connective tissue diseases). The presence of the male-specific SRY sequence was analyzed using a kinetic quantitative ELISA PCR assay that allows detection of one to three male cells in one million female cells. The percentage of SRY-positive samples was not different among women having borne son(s): 16% (95% confidence interval 0.07-0.29) in healthy controls, 21.7% (0.07-0.44) in patients with scleroderma and 25.5% (0.14-0.40) in patients with connective tissue diseases (p=0.25). The mean number of fetal cells was similar in the three groups. Among the 121 females who never carried a male fetus, no healthy woman was SRY positive. However, 33% of patients with scleroderma and 22.9% of women with connective tissue diseases were chimeric, a phenomenon which might be related to early miscarriage(s). Therefore, feto-maternal microchimerism is a common event in both healthy controls and patients with connective tissue diseases, and is unlikely to represent per se a risk factor for these diseases.

Pregnancy and successful labor in the course of chronic lymphocytic leukemia

Pregnancy and leukemia are difficult to manage. Protecting the mother from hemorrhage and infection and the fetus from developmental failure are the main aims. Chronic lymphocytic leukemia (CLL) has been seen very rarely with pregnancy. In this article, the successful labor of a 43-year-old woman with CLL is reported. She was not a candidate for chemotherapy at that time. She was without symptoms when she got pregnant. In the 30th gestational week she was found to have urinary tract infection and preterm labor and she was stabilized. Gestational diabetes and preeclampsia were also determined after that period and managed. The patient was delivered by cesarean section in the 39th gestational week. Cord blood was collected and preserved. No postpartum complication was seen in either the patient or the infant. This is one of the rare cases presenting CLL with pregnancy in the literature.

Blood transfusions as a risk factor for non-Hodgkin's lymphoma in the San Francisco Bay Area: a population-based study

The incidence of non-Hodgkin's lymphoma (NHL) has risen dramatically over the past 50 years. In the search for new risk factors, blood transfusions have been investigated and shown to be associated with subsequent lymphoma in some studies. The authors tested this association in a population-based, case-control study conducted between 1988 and 1995 in the San Francisco Bay Area of California. A total of 1,591 histologically confirmed adult cases of NHL were included in this study. Cases were frequency matched to 2,515 control participants by sex, county of residence, and 5-year age intervals. Multivariate logistic regression models were used to examine the impact of possible confounders. Persons who reported a history of allogeneic transfusion were not at increased risk of NHL in this population (odds ratio (OR) = 1.0, 95% confidence interval (CI): 0.84, 1.2). No significant associations were seen when lymphomas were stratified by histologic subtype, grade, or latency period. However, autologous transfusions were associated with a decreased risk (OR = 0.39, 95% CI: 0.16, 0.94). In summary, these findings are similar to those of prior negative studies and do not support some previous reports of an adverse association between blood transfusion and NHL.

Effect of pathological perinatal conditions on the maternofetal transfer of mononuclear cells

OBJECTIVE

It is known that mononuclear cells can cross the placenta in both directions: from mother to fetus and the other way. In addition, it has been shown that perinatal pathological conditions can affect the fetomaternal cell transfer. This study has focused on the question whether perinatal conditions will also support the transfer of maternal cells in the fetus.

METHODS

Minisatellite polymerase chain reaction (PCR) with a sensitivity of 1:100 was used to examine blood samples of 36 mother-child pairs for transplacental mononuclear cell transfer (group 1). Furthermore, 28 blood samples of mother-child pairs were examined by allele-specific PCR (sensitivity 1:1,000) for maternofetal mononuclear cell transfer; only 9 of these mother-child pairs were informative (group 2).

RESULTS

Three cases of maternofetal and 2 additional cases of fetomaternal mononuclear cell transfer could be documented in group 1; 2 of the 9 informative samples in group 2 showed a maternofetal mononuclear cell transfer. In conclusion, 9 of 40 cases lacking maternofetal cell transfer and 4 of 5 cases with maternofetal cell transfer were high-risk deliveries (p < 0.01).

CONCLUSION

The current study shows that certain ante-partum conditions like placental insufficiency or chorioamnionitis increase significantly the chance that maternal cells enter the fetus.

Persistent maternally derived peripheral microchimerism is associated with the juvenile idiopathic inflammatory myopathies

OBJECTIVE

Fetal cells have been demonstrated in the active lesions of adult women with systemic sclerosis. Because the juvenile idiopathic inflammatory myopathies (JIIM) share clinical and histopathological features with systemic sclerosis and graft-vs-host disease, we explored the possibility that maternal cells persist and play a role in the pathogenesis of JIIM.

METHODS

DNA samples extracted from peripheral blood of 28 JIIM patients (14 females, 14 males) and 23 healthy controls were assessed for microchimerism by the HLA Cw polymerase chain reaction method. HLA Cw alleles from eight mothers and three healthy siblings of JIIM patients were also examined.

RESULTS

A microchimeric allele was identified in 19 of 26 JIIM patients whose data were able to be interpreted, compared with two of 21 healthy controls (P<0.001). Subjects with microchimerism ranged in age from 4 to 28 yr. In eight cases in which maternal peripheral blood was available, the additional Cw allele present in the patients was confirmed to be identical to a maternal allele. Three healthy siblings of JIIM patients did not have evidence of a microchimeric Cw allele.

CONCLUSION

Maternal cells can persist in the peripheral blood of their children up to three decades after birth, and are found in a higher proportion in JIIM patients compared with controls. These findings, with other data, suggest that maternal cells may be involved in the immunopathogenesis of JIIM.

Clearance of maternal leukaemic cells in a neonate

A 36-week pregnant woman was diagnosed with acute lymphoblastic leukaemia. Delivery was initiated prematurely, and a healthy child was born. Cord blood and peripheral blood samples from the neonate (obtained at 6 weeks, 3 months and 6 months) were analysed for the presence of minimal residual disease by polymerase chain reaction analysis of a leukaemia-specific IGH gene rearrangement and the E2A--PBX1 fusion gene transcript. In the cord blood sample, a tumour load of approximately 4 x 10(-4) was found, whereas all later blood samples were negative. Our data indicate that the maternal leukaemic cells did not engraft in the neonate.

Natural killer cell lymphoma: report of two pediatric cases, therapeutic options, and review of the literature

BACKGROUND

Natural killer (NK) cell lymphomas are rapidly fatal malignancies that to the authors' knowledge are rare in children. In the current study, the authors report the cases of two boys with NK cell lymphomas with refractory disease who both were salvaged with high dose chemotherapy and stem cell transplantation and compare these patients with those in the published experience.

METHODS

A comprehensive literature review was performed to identify other cases of pediatric patients with NK cell lymphomas, their treatment, and outcome.

RESULTS

One of the patients in the current study developed two recurrences and the other patient experienced early disease progression during front-line treatment. Both then were treated with high dose chemotherapy followed by stem cell rescue. At last follow-up, the patients remained free of disease at 15 months and 16 months, respectively, after transplantation (48 months and 22 months, respectively, from the time of diagnosis). In addition to the 2 patients in the current study, the authors found 13 pediatric patients reported in the literature to date. Of the 7 patients with localized (Stage I-II) disease, 5 patients (71%) were reported to be alive 1-107 months after diagnosis. Of the 6 patients with Stage IV disease, only the 2 patients who received high dose chemotherapy and stem cell rescue (33%) were alive at the time of last follow-up (at 30 months and 12 months, respectively). Including the patients reported in the current study, 9 of 15 children with NK cell lymphoma (all stages) (60%) were reported to be alive at the time of last follow-up.

CONCLUSIONS

Although pediatric NK cell lymphomas rapidly can become fatal, it appears that high dose chemotherapy followed by stem cell transplantation is effective therapy, especially in patients with advanced or resistant disease. Further follow-up is needed to determine whether this treatment approach will be curative.