VS38: a new monoclonal antibody for detecting plasma cell differentiation in routine sections

VS38c and CD38-Multiepitope Antibodies Provide Highly Comparable Minimal Residual Disease Data in Patients With Multiple Myeloma

Objectives

To compare flow cytometric minimal residual disease (MRD) data obtained using the EuroFlow approach, including the CD38-multiepitope (ME) antibody or the VS38c antibody.

Methods

We evaluated 29 bone marrow samples from patients with multiple myeloma (MM), of whom 15 had received daratumumab within the past 6 months. We evaluated MRD data and fluorescence intensities.

Results

Qualitative MRD data were 100% concordant between the 2 approaches. In MRD-positive samples (n = 14), MRD levels showed an excellent correlation (R² = 0.999). Whereas VS38c staining was strong in both normal plasma cells and MM cells, independent of daratumumab treatment, staining intensities for CD38 were lower in MM cells compared with normal plasma cells, and on both cell types CD38 expression was significantly reduced in daratumumab-treated patients.

Conclusions

Both CD38-ME and VS38c allow reliable MRD detection in MM patients, but the high expression of VS38c allows easier identification of MM cells, especially in daratumumab-treated patients.

Limitations of VS38c labeling in the detection of plasma cell myeloma by flow cytometry

Plasma cell myeloma (multiple myeloma [MM]) is a malignant neoplasm originating from the plasma cells. Besides other methods, flow cytometric analysis of the patient's bone marrow aspirate has an important role in the diagnosis and also in the response assessment. Since the cell surface markers, used for identifying abnormal plasma cells, are expressed diversely and the treatment can also alter the phenotype of the plasma cells, there is an increasing demand for new plasma cell markers. VS38c is a monoclonal antibody that recognizes the CLIMP-63 protein in the membrane of the endoplasmic reticulum. CLIMP-63 is known to be expressed at high levels in normal and pathologic plasma cells in the bone marrow, thus VS38c antibody can be used to identify them. Although VS38c staining of plasma cells is reported to be constant and strong even in myeloma, we were wondering whether sample preparation can affect the staining. We have investigated the effect of different permeabilization agents and washing of the cells on the quality of the VS38c staining and found that in many cases the staining is inadequate to identify the plasma cells. We measured the VS38c staining of the bone marrow aspirates of 196 MM patients and observed that almost all cases showed bright staining with VS38c. However, permeabilization with mild detergent resulted in the appearance of a significant VS38c^dim subpopulation, which showed increased sensitivity to mechanical stress (centrifugation). Our results indicate that VS38c^dim MM cells can appear due to the improper permeabilization of the endoplasmic reticulum and this finding raises the possibility of the existence of a plasma cell subpopulation with different membrane properties. The significance of this population is unclear yet, but these cells can be easily missed with VS38c staining and can be lost due to centrifugation-induced lysis during sample preparation.

VS38 staining contributes to a novel gating strategy in flow cytometry for small B cell lymphoma, especially in lymphoplasmacytic lymphoma/Waldenström macroglobulinemia

BACKGROUND

Multi-parametric flow cytometry (MFC) is a helpful tool for detecting neoplastic cells in malignant lymphoma; however, lymphoma cells can be difficult to detect when characteristic immunophenotypic abnormalities are not evident. We evaluated the stainability of VS38, which is used for multiple myeloma, in normal and abnormal B cells using MFC to develop a new strategy for detecting lymphoma cells.

METHODS

We compared the median fluorescence intensity of VS38 staining in lymphocytes from patients without hematopoietic neoplasms and in B cells from 26 patients with B cell lymphoma (BCL). To evaluate the performance of VS38 gating, we compared VS38-positive B cells with the percentages of BCL cells, and with the mutation ratios of MYD88 L265P measured by droplet digital PCR in patients with lymphoplasmacytic lymphoma (LPL)/Waldenström macroglobulinemia (WM).

RESULTS

CD27-positive memory B cells were stained with VS38, whereas normal lymphocytes were faintly stained. Lymphoma cells were stained with VS38 in 11 of 12 patients with LPL/WM, 3 of 3 with chronic lymphocytic leukemia, 3 of 5 with mantle cell lymphoma, 2 of 4 with follicular lymphoma, and 1 of 1 with splenic marginal zone lymphoma. The percentages of VS38-positive B cells in VS38-positive BCL were equivalent to those of lymphoma cells and the mutation ratios of MYD88 L265P in LPL/WM.

CONCLUSIONS

VS38 identified neoplastic cells in plasma cell disorders and BCL. This might improve the accuracy of BCL diagnosis, especially in patients with LPL/WM.

An autopsy case of acute myocarditis with unique lymph node findings characterized by the proliferation of reactive plasmablasts

We report an autopsy case of acute myocarditis, in which the mediastinal lymph nodes exhibited unique findings. A 15-year-old Japanese boy was diagnosed with the secondary onset of acute myocarditis. No viruses were identified. Autopsy confirmed acute lymphocytic myocarditis. Lymphadenopathy was observed, especially in pulmonary hilar/mediastinal areas. Microscopically, interfollicular areas were uniformly filled with medium-sized, round cells that resembled lymphocytes. They were immunohistochemically CD3^- CD5^- CD19⁺ CD20^- CD79a^- Pax-5^- CD138⁺ MUM1⁺ LMP1^- EBNA2^- cytoplasmic IgG⁺ IgA^- and IgM^-. No monotypia was observed for kappa and lambda light chains, and multiplex polymerase chain reaction analyses of immunoglobulin heavy chain variable region diversity demonstrated oligoclonal peaks, suggesting reactive change. IgG⁺ or VS38c⁺ cells frequently co-expressed Ki-67 (up to 80%). We considered these cells abundantly present in lymph nodes to be reactive plasmablasts because they were early plasma cells with proliferative activity.

VS38 Identifies Myeloma Cells With Dim CD38 Expression and Plasma Cells Following Daratumumab Therapy, Which Interferes With CD38 Detection for 4 to 6 Months

OBJECTIVES

We report our institutional experience using VS38 to evaluate plasma cells by flow cytometry.

METHODS

Flow cytometry data were reanalyzed to compare plasma cell percentages between the standard panel and VS38 panel. Natural killer (NK) and plasma cell CD38 median fluorescence intensity (MFI) values were calculated.

RESULTS

Our cohort included 63 specimens from 38 patients. Twenty-six had received daratumumab (monoclonal anti-CD38 therapy) between less than 1 month and 17 months prior. For NK and plasma cells, CD38 MFI values were suppressed for 0 to 4 months and started to increase 4 to 6 months after last exposure. There was no significant difference in clonal plasma cell percentage calculated by the VS38 and standard panels; however, identification and quantification using the VS38 panel were easier.

CONCLUSIONS

VS38 is a viable alternative to bright CD38 to identify plasma cells and particularly helpful in myeloma cases with dim CD38 and after daratumumab. Daratumumab interference with CD38 identification persists 4 to 6 months after the last exposure.

Next generation flow for minimally-invasive blood characterization of MGUS and multiple myeloma at diagnosis based on circulating tumor plasma cells (CTPC)

Here, we investigated for the first time the frequency and number of circulating tumor plasma cells (CTPC) in peripheral blood (PB) of newly diagnosed patients with localized and systemic plasma cell neoplasms (PCN) using next-generation flow cytometry (NGF) and correlated our findings with the distinct diagnostic and prognostic categories of the disease. Overall, 508 samples from 264 newly diagnosed PCN patients, were studied. CTPC were detected in PB of all active multiple myeloma (MM; 100%), and smoldering MM (SMM) patients (100%), and in more than half (59%) monoclonal gammopathy of undetermined significance (MGUS) cases (p <0.0001); in contrast, CTPC were present in a small fraction of solitary plasmacytoma patients (18%). Higher numbers of CTPC in PB were associated with higher levels of BM infiltration and more adverse prognostic features, together with shorter time to progression from MGUS to MM (p <0.0001) and a shorter survival in MM patients with active disease requiring treatment (p ≤ 0.03). In summary, the presence of CTPC in PB as assessed by NGF at diagnosis, emerges as a hallmark of disseminated PCN, higher numbers of PB CTPC being strongly associated with a malignant disease behavior and a poorer outcome of both MGUS and MM.

Minimal Residual Disease Detection by Flow Cytometry in Multiple Myeloma: Why and How?

The outlook for myeloma patients has steadily improved with the introduction of newer drug combinations in recent years. Unlike older therapies that largely achieved only modest levels of neoplastic clone reduction, the newer drug combinations have led to deeper suppression of myeloma clones in most patients. Frequently the neoplastic clones become undetectable with traditional disease evaluation approaches. Recent studies using ultrasensitive disease monitoring have demonstrated that patients with disease undetectable by traditional techniques show wide heterogeneity in disease levels varying by several orders of magnitude. Moreover, measurement of the depth of disease suppression even at very low level has emerged as the most powerful prognostication tool in myeloma. Minimal (or measurable) residual disease (MRD) evaluation has also been proposed as a relevant tool in assessment of drug efficacy and in selection of further therapeutic options. In the face of the robust MRD measurement utility data, it has become critical to develop widely applicable disease monitoring techniques that can be applied to more patients in a variety of clinical setting. Both DNA-based and flow cytometry-based approaches have been successfully developed for this purpose achieving sensitivity approaching 1 neoplastic cell in a million. This review article focuses on the theoretical and practical aspects and challenges of deep MRD monitoring in myeloma by flow cytometry. Challenges of flow cytometric disease monitoring in the era of antigen-directed therapy are also discussed.

Utility of VS38c in the diagnostic and prognostic assessment of osteosarcoma and other bone tumours/tumour-like lesions

Background

VS38c is a monoclonal antibody that recognises a rough endoplasmic reticulum (rER) intracellular antigen termed cytoskeleton-linking membrane protein 63. rER is typically found in viable tumour cells and is abundant in osteosarcoma cells. The aim of this study was to determine the diagnostic and prognostic utility of VS38c in the histological assessment of osteosarcoma and other bone tumours/tumour-like leisons.

Methods

Immunohistochemical staining with VS38c was carried out on formalin-fixed specimens of osteosarcoma (pre/post-chemotherapy) and a wide range of benign and malignant bone lesions. In addition, VS38c staining of cultures of MG63 and Sa0S2 osteosarcoma cell cultures. (±cisplatin and actinomycin D-treatment) was analysed.

Results

VS38c strongly stained tumour cells in all low-grade and high-grade osteosarcomas and in undifferentiated sarcomas and high-grade chondrosarcomas. There was little or no VS38c staining of low-grade chondrosarcomas or chordomas and variable staining of Ewing sarcomas. Osteoblasts in benign bone-forming tumours and mononuclear stromal cells in chondroblastomas, giant cell tumours and non-ossifying fibromas strongly stained for VS38c. VS38c staining was absent in cisplatin and actinomycin D treated Sa0S2 and MG63 cells. In specimens of osteosarcoma post-neoadjuvant therapy, VS38c staining was absent in most morphologically necrotic areas of tumor although some cells with pyknotic nuclei stained for VS38c in these areas. Most tumour cells exhibiting atypical nuclear forms were not stained by VS38c.

Conclusions

Our findings show that VS38c is a sensitive but not specific diagnostic marker of osteosarcoma. Staining with VS38c identifies viable osteosarcoma cells, a feature which may be useful in the assessment of percentage tumour necrosis post-neoadjuvant chemotherapy.

[Space-occupying lesion of the ribs]

An osteolytic tumor of the 7(th) rib was surgically removed from a 40-year-old patient. Immunohistochemical investigations showed that neither epithelial markers nor B and T cell markers were expressed in the tumor tissue; however, there was strong expression of VS38 and vimentin. These results were compatible with a solitary plasmocytoma of the bone. Further immunohistochemical investigations detected an expression of the melanoma markers S-100 and melan-A. The diagnosis of a metastasis of an amelanotic malignant melanoma could therefore be verified.

Hypergammaglobulinemia in an SIV-infected rhesus macaque with a B-cell neoplasm with plasma cell differentiation

An SIV-infected rhesus macaque presented with anemia, hypercalcemia, and hyperglobulinemia. Neoplastic round cells with plasma cell morphology infiltrated multiple organs and stained immunohistochemically positive for CD45, MUM1/IRF4, CD138, VS38C, and Kappa light chain and variably positive for CD20 and CD79a, consistent with a B-cell neoplasm with plasma cell differentiation.

Update on the Diagnosis and Classification of the Plasma Cell Neoplasms

The plasma cell neoplasms are malignancies of the most terminally differentiated cells in B-cell ontogeny and are usually associated with the production of a monoclonal immunoglobulin molecule or M protein. These malignancies include tumors whose clinical manifestations are directly attributable to the end-organ damage induced by the dysregulated proliferation of neoplastic plasma cells. In contrast, disorders, such as primary amyloidosis, have a paradoxically low burden of neoplastic plasma cells, rendered highly pathogenic by the end-organ damage induced by deposition of the secreted paraprotein. In this article, discussion focuses on plasma cell myeloma. The molecular pathogenesis of plasma cell myeloma is reviewed and the diagnosis of the plasma cell neoplasms discussed.

Solitary pleural plasmacytomas manifested as a massive pleural effusion without evidence of monoclonal gammopathy

The majority of extramedullary plasmacytomas involve the upper respiratory tract but only a few are associated with serum monoclonal gammopathy. Most extramedullary plasmacytomas respond to local radiotherapy and have a better prognosis than multiple myeloma. Solitary plasmacytomas, involving the pleura, are very rare. This case report describes a patient with a solitary extramedullary plasmacytoma involving the pleura, and no evidence of serum, urine or pleural fluid paraproteins. Diagnosis was made by strongly positive immunohistochemical stains with CD38, CD138 and MUM-1 of the pleural tumour. The response to both radiotherapy and chemotherapy was poor and the patient died shortly after diagnosis.

Assessment of bone marrow plasma cell infiltrates in multiple myeloma: the added value of CD138 immunohistochemistry

Assessment of bone marrow involvement by malignant plasma cells is an important element in the diagnosis and follow-up of patients with multiple myeloma and other plasma cell dyscrasias. Microscope-based differential counts of bone marrow aspirates are used as the primary method to evaluate bone marrow plasma cell percentages. However, multiple myeloma is often a focal process, a fact that impacts the accuracy and reliability of the results of bone marrow plasma cell percentages obtained by differential counts of bone marrow aspirate smears. Moreover, the interobserver and intraobserver reproducibility of counting bone marrow plasma cells microscopically has not been adequately tested. CD138 allows excellent assessment of plasma cell numbers and distribution in bone marrow biopsies. We compared estimates of plasma cell percentages in bone marrow aspirates and in hematoxylin-eosin- and CD138-stained bone marrow biopsy sections (CD138 sections) in 79 bone marrows from patients with multiple myeloma. There was a notable discrepancy in bone marrow plasma cell percentages using the different methods of observation. In particular, there was a relatively poor concordance of plasma cell percentage estimation between aspirate smears and CD138 sections. Estimates of plasma cell percentage using CD138 sections demonstrated the highest interobserver concordance. This observation was supported by computer-assisted image analysis. In addition, CD138 expression highlighted patterns of plasma cell infiltration indicative of neoplasia even in the absence of plasmacytosis. We conclude that examination of CD138 sections should be considered for routine use in the estimation of plasma cell load in the bone marrow.

A new xenograft model of myeloma bone disease demonstrating the efficacy of human mesenchymal stem cells expressing osteoprotegerin by lentiviral gene transfer

We describe a new model of myeloma bone disease in which beta2m NOD/SCID mice injected with KMS-12-BM cells develop medullary disease after tail vein administration. Micro-computed tomography analysis demonstrated significant bone loss in the tibiae and vertebrae of diseased animals compared to controls, with loss of cortical bone (P<0.01), as well as trabecular bone volume, thickness and number (P<0.05 for all). Bone marrow of diseased animals demonstrated an increase in osteoclasts (P<0.01) and reduction in osteoblasts (P<0.01) compared to control animals. Both bone loss and osteoclast increase correlated with the degree of disease involvement. Mesenchymal stem cells (MSCs) were lentivirally transduced to express human osteoprotegerin (hOPG). Systemic administration of OPG expressing MSC reduced osteoclast activation (P<0.01) and trabecular bone loss in the vertebrae (P<0.05) and tibiae of diseased animals, to levels comparable to non-diseased controls. Because of its predominantly medullary involvement and quantifiable parameters of bone disease, the KMS-12-BM xenogeneic model provides unique opportunities to test therapies targeted at the bone marrow microenvironment.

Diagnosis and Classification of Malignant Lymphoma and Related Entities in the Bone Marrow Trephine Biopsy

The trephine bone marrow (BM) biopsy is an important diagnostic tool in patients with malignant lymphoma. BM examination can serve to establish or confirm a primary diagnosis of lymphoma or to determine the extent of disease dissemination for staging purposes. BM histology renders information which cannot be gained equally from aspirate material, such as spacial distribution and extent of infiltrates, BM cellularity and fibrosis. Furthermore, cytology including flow cytometric immunophenotyping can give false-negative results in BM involvement by lymphoma due to intralesional fibrosis. In addition to morphological examination, the availability of a broad panel of antibodies suitable for paraffin-embedded tissues, in conjunction with less damaging decalcification procedures, nowadays enables us to perform complete immunophenotyping on BM trephines and allows for classification of lymphoma infiltrates according to established algorithms. Molecular determination of clonality and interphase fluorescent in situ hybridization can be employed selectively to resolve difficult cases. This review describes important diagnostic features of malignant lymphoma in the BM, relevant differential diagnoses, and the proper use of ancillary techniques.

Cerebral AL lambda-amyloidoma: clinical and pathomorphological characteristics. Review of the literature and of a patient

BACKGROUND

Amyloid deposits within the brain can be found in a heterogeneous group of diseases. Some of them involve only the central nervous system (AD); others are of systemic origin. Isolated deposits either in the brain, cranial nerves or within the spinal neural structures are extremely rare. So far, we do not know the natural origin, nor the clinical course.

METHODS

We reviewed the overall published cases as far as available and added our own case to learn more about the natural history, clinical and imaging characteristics of this rare brain lesion.

RESULTS

Together with our own case, 27 patients with cerebral amyloidoma were collected in the literature. The lesion always occurred supratentorially, moreover in another two cases also infratentorially. The initial symptoms as well as the results of different neuroimaging features were not specific. There was no predominance for sex and localization. Diagnosis could only be established by histopathological examination after surgical intervention. No recurrence was seen after radical resection; but there was progression in some cases of tumor biopsy.

CONCLUSION

Complete surgical removal of cerebral AL amyloidoma seems to be the only way to prevent progression or recurrence of such a brain lesion.

Immunization-induced perturbation of human blood plasma cell pool: progressive maturation, IL-6 responsiveness, and high PRDI-BF1/BLIMP1 expression are critical distinctions between antigen-specific and nonspecific plasma cells

The present study shows that reimmunization with tetanus toxoid (tet) caused a transient increase of the human blood plasma cell (PC) pool, detectable from 6th to 15th day postboost, as well as the temporal alteration of several PC features. Labeling of specific PC with FITC-tet C fragment (tetC) allowed kinetics analysis of the tetC(+) and tetC(-) PC, and revealed remarkable differences between them: 1) the kinetics of tetC(+) PC occurrence was exponential, and most of them appeared in a narrow time frame (5th to 8th day postboost), whereas the tetC(-) PC increase was lower (three to five times) and more prolonged (4th to 15th day postboost). 2) The tetC(+) PC subset contained a fraction of cycling cells, expressed high levels of DR, CD138, and CD126, and responded to IL-6 by improving their survival and Ig secretion; in contrast, the tetC(-) PC showed higher CXCR4 and lower DR and CD138, did not respond to IL-6, and contained a fraction of apoptotic cells. 3) Sequential phenotypic analysis revealed maturational changes within the tetC(+), but not tetC(-), PC subset; sequencing of tetC(+) PC IgVH genes showed clear features of Ag selection. 4) The tetC(+) PC expressed several times more positive regulatory domain I- binding factor 1/B lymphocyte-induced maturation protein 1 transcription factor than the tetC(-) PC. 5) The tetC(-) PC and bone marrow resident PC similarly expressed low DR and high CXCR4, but differed in that the latter exhibited higher levels of CD31, CD138, and positive regulatory domain I- binding factor 1/B lymphocyte-induced maturation protein 1. These findings support the view that tetC(+) PC contain bone marrow PC precursors, and tetC(-) PC probably belong to a removable compartment of aged PC.

Diffuse large B-cell lymphomas with plasmablastic differentiation

Recent evidence suggests that diffuse large B-cell lymphoma (DLBCL) with plasmablastic differentiation represents a clinically heterogeneous spectrum with different clinicopathologic characteristics representing distinct entities. Subtypes of DLBCL with plasmablastic features and terminal B-cell differentiation include plasmablastic lymphoma (PBL) of oral mucosa type; PBL with plasmacytic differentiation; primary effusion lymphoma (PEL); KSHV-positive solid lymphoma/extracavitary PEL/HHV-8 associated DLBCL; and DLBCL expressing ALK. In contrast, PBL associated with multicentric Castleman disease, DLBCL with secretory differentiation, pyothorax-associated lymphoma, and atypical Burkitt lymphoma with plasmacytoid differentiation have morphologic appearances of plasma cell differentiation but maintain a mature B-cell (CD20 positive) phenotype. These tumors as well as extramedullary plasmablastic tumors secondary to multiple myeloma or plasmacytomas are included in the differential diagnosis. In this review, we discuss recently described clinicopathologic insights, case observations, and recently reported molecules involved in terminal B-cell or plasma cell differentiation and their possible roles in disease pathogenesis.

KSHV/HHV-8 associated lymph node based lymphomas in HIV seronegative subjects. Report of two cases with anaplastic large cell morphology and plasmablastic immunophenotype

BACKGROUND

Kaposi sarcoma associated herpesvirus (KSHV)/human herpesvirus 8 (HHV-8) associated lymphomas, which often develop in human immunodeficiency virus (HIV) infected patients with advanced AIDS, present predominantly as primary effusion lymphoma (PEL) or, less frequently, as "solid" extracavitary based lymphomas, associated with serous effusions. These last lymphomas, also called "solid PEL", have been reported before the development of an effusion lymphoma and after resolution of PEL. Interestingly, KSHV/HHV-8 associated lymphomas that present as solid or extracavitary based lesions in HIV seropositive patients without serous effusions have been reported recently.

METHODS/RESULTS

This paper provides evidence for the existence of a previously undescribed KSHV/HHV-8 associated lymphoma in HIV seronegative patients without serous effusions. These lymphomas exhibit a predilection for the lymph nodes and display anaplastic large cell morphology. These tumours were completely devoid of common cell type specific antigens, including epithelial and melanocytic cell markers. B and T cell associated antigens and other commonly used lymphoid markers were absent or weakly demonstrable in a fraction of the tumour cells. Conversely, immunohistochemical studies showed strong immunostaining with plasma cell reactive antibodies.

CONCLUSIONS

Analysis of viral infection and immunohistological studies are of primary importance to define this lymph node based KSHV/HHV-8 associated lymphoma with anaplastic large cell morphology and plasmablastic immunophenotype occurring in HIV seronegative patients without serous effusions.

Expression of TRAIL and TRAIL receptors in normal and malignant tissues

TRAIL, tumor necrosis factor-related apoptosis-inducing ligand, is a member of the TNF family of proteins. Tumour cells were initially found to have increased sensitivity to TRAIL compared with normal cells, raising hopes that TRAIL would prove useful as an anti-tumor agent. The production of reliable monoclonal antibodies against TRAIL and its receptors that can stain fixed specimens will allow a thorough analysis of their expression on normal and malignant tissues. Here we report the generation of monoclonal antibodies against TRAIL and its four membrane-bound receptors (TR1-4), which have been used to stain a range of normal and malignant cells, as routinely fixed specimens. Low levels of TRAIL expression were found to be limited mostly to smooth muscle in lung and spleen as well as glial cells in the cerebellum and follicular cells in the thyroid. Expression of the TRAIL decoy receptors (TR3 and 4) was not as widespread as indicated by Northern blotting, suggesting that they may be less important for the control of TRAIL cytotoxicity than previously thought. TR1 and TR2 expression increases significantly in a number of malignant tissues, but in some common malignancies their expression was low, or patchy, which may limit the therapeutic role of TRAIL. Taken together, we have a panel of monoclonal antibodies that will allow a better assessment of the normal role of TRAIL and allow assessment of biopsy material, possibly allowing the identification of tumors that may be amenable to TRAIL therapy.

Centrocytoid Plasma Cells of the Germinal Center

Germinal centers within the lymph node follicles are T-cell-dependent, antigen-driven B-cell proliferations that develop from the rapid clonal expansion of a few founder cells. The end results of this B-cell expansion are memory B cells or plasma cells. Two morphologic forms of plasma cell can be recognized in the germinal center: classic plasma cells, characterized morphologically by peripherally clumped arrangement of nuclear chromatin, and cells with a nuclear morphology more resembling that of the centrocytes, which the authors have termed "centrocytoid plasma cells." In this study the authors examined the distribution and immunohistochemical characteristics of these two populations of germinal center plasma cells. The centrocytoid plasma cells were arranged in a band stretching from the junction of the dark and light zone to the periphery of the germinal centers, while the classic plasma cells were mainly present at the germinal center periphery. Both marked with CD38, CD138, and VS38c, recognized markers for plasma cells; however, EMA and CD31 were present only in the classic form of plasma cell. The proliferation marker Ki67 was present in less than 1% of the cells labeling with CD138. Others have demonstrated Ki67 in 50% of the cells labeled with Blimp-1, which is consistent with Blimp-1 appearing earlier than CD138 in ontogeny. CD10 is co-expressed with CD138 in about 10% of cells and CD45 with CD138 in about 5% of cells. Their topographic features, together with the progressive acquisition of plasma cell markers, suggest that the centrocytoid plasma cells may be the precursors of the classic plasma cells. Of note, both the forms of plasma cell were absent in follicles of follicular lymphoma, which supports the concept that in this disease, lymphocytes fail to differentiate and mature beyond the centrocyte stage.

Lymphome plasmoblastique du sujet infecté par le VIH : à propos d’un cas très inhabituel de localisation cutanée

We report the case of a plasmablastic lymphoma involving the skin in a 45 year-old HIV-positive patient. Plasmablastic lymphoma was first described in 1997 and is considered to be a diffuse large B-cell lymphoma with a unique immunophenotype and a predilection for the oral cavity. In this case, the tumor was revealed by multiple purple cutaneous nodules predominantly localized on the trunk and proximal parts of the limbs. A skin biopsy led to the diagnosis of plasmablastic lymphoma in view of the presence of a dense nodular infiltrate invading the dermis and subcutaneous fat composed of large cells that expressed neither the leucocyte common antigen nor the B- and T-cell antigens CD20 and CD3, but which showed a strong immunostaining with plasma cell marker VS38c. Most of the cells expressed Kappa light chain of immunoglobulins, they did not express Lambda light chain. In situ hybridization with EBER probe revealed detection of Epstein Barr virus in about 15 % of tumor cells. The clinical course was aggressive and rapidly fatal. Despite one cycle chemotherapy the patient died four months after presentation. HIV-associated plasmablastic lymphoma is a poor prognosis malignancy that may resist typing due to the lack of expression of commonly used lymphoid markers.

A new immunofluorostaining method using red fluorescence of PerCP on formalin-fixed paraffin-embedded tissues

Immunofluorostaining, a versatile tissue staining method, is used in biomedical research because of its clear contrast and precise quantification of positive signals. However, its application in clinical diagnosis has been limited. A major obstacle is high fluorescent background of formalin-fixed, paraffin-embedded tissue sections (paraffin sections). On paraffin sections, strong and broad fluorescence of the section overlapping that of conventional fluorescent dyes such as fluorescein isothiocyanate (FITC) prevents detection of target immunofluorescence. To circumvent the background, we selected an albuminous dye, peridinin chlorophyll a protein (PerCP), for immunostaining of human tumor sections with tumor-reactive monoclonal antibodies. Red fluorescence of PerCP clearly distinguished the tumor region within the yellow-green autofluorescence of the section. Furthermore, it was possible to observe tissue morphology simultaneously without any counterstaining; autofluorescence served as counterstaining in this method. Digital quantification of PerCP-stained image intensity correlated (r2>0.99) well with extracted PerCP amount, indicating the usefulness of image quantification. We conclude that this new and simple immunofluorostaining method can be applied to pathological diagnosis of a wide range of conditions, including cancer.

Russell body gastritis: an unusual, tumor-like lesion of the gastric mucosa

The case of an 80-year-old woman who presented with epigastric symptoms is reported. Upper gastrointestinal endoscopy displayed Candida esophagitis and a localized swelling of the fundic mucosa. Histologic examination of the gastric biopsy showed a distinctive accumulation of numerous uniform plasma cells filled with so-called Russell bodies. On low-power view, the lesion resembled a neoplastic process due to the marked expansion of the lamina propria with distension of fundic glands. However, immunohistochemistry confirmed a polyclonal pattern of the plasma cells. This unusual reactive lesion of the gastric mucosa has only rarely been described and has been termed Russell body gastritis.

Variability in immunophenotype in diffuse large B-cell lymphoma and its clinical relevance

Diffuse large B-cell lymphoma (DLBCL), the single largest category of lymphoma, is a clinically and biologically heterogeneous disease entity. Clinically, patients differ in their mode of presentation and respond variably to therapy. A combination of clinical parameters can be used to predict the patient's response to therapy and survival. The pathological variability of DLBCL is expressed in morphology, immunophenotype, cytogenetic and molecular genetic features. Numerous markers detectable by immunohistochemistry and linked to different aspects of tumour biology have been studied in DLBCL, including lineage-associated and immune markers, proliferation and apoptosis markers, cell adhesion molecules, and more recently stage-specific markers of B-cell differentiation. This review summarizes these studies in regard to their clinical significance and in the light of recent advances in our understanding of the molecular pathology and histogenesis of DLBCL.

Diffuse large B-cell lymphoma of bone: an analysis of differentiation-associated antigens with clinical correlation

Twenty-nine patients with diffuse large B-cell lymphomas presenting with bone involvement, including 18 localized primary bone lymphomas (group 1), 2 multifocal primary bone lymphomas (group 2), and 9 patients with extraskeletal disease at diagnosis (group 3), were studied. The tumors were subclassified according to the criteria of the WHO classification and evaluated by immunohistochemistry for expression of antigens associated with germinal center (GC) and non-GC stages of B-cell differentiation (bcl-6, CD10, MUM-1, VS38c, CD138, bcl-2, and CD44). The presence of a BCL-2/IgH gene rearrangement was investigated by polymerase chain reaction. All cases were characterized by similar clinicopathologic and morphologic features and had similarly good overall outcome. The patients (23 males, 6 females, median age 44 years) had tumors in long bones (14), axial skeleton (8), limb girdles (3), and multiple sites (4). Most tumors (24) were centroblastic, with multilobated cells in 12 cases. Almost half of the tumors (14 of 29, 48%) were bcl-6+CD10+ (GC-like), 9 of 29 cases (31%) were bcl-6+CD10- (indeterminate phenotype), and 6 of 29 cases (21%) were CD10-bcl-6- (post-GC like). The indeterminate phenotype was seen only in primary bone lymphoma. MUM-1 was frequently expressed in GC-like and non-GC-like categories. We found no evidence of plasmacytic differentiation by CD138, and VS38c immunoreactivity was distinctly rare (2 of 29 cases). CD44 was detected in 6 tumors, all CD10-. Bcl-2 was expressed by 70% of the tumors, but only 1 of 23 cases tested had a Bcl-2/JH rearrangement by polymerase chain reaction. A survival analysis showed that GC-like tumors had a longer overall survival duration compared with non-GC-like tumors (P = 0.0046). In conclusion, a GC-like immunophenotype characterizes roughly half of large B-cell lymphomas of bone and is associated with an improved survival.

Bone marrow immunohistology of plasma cell neoplasms

The application of immunohistology to the spectrum of plasma cell disorders has yet to be incorporated widely into routine haematology practice. This technique enables the direct visualisation of specific surface and cytoplasmic antigens in the context of the individual cell and the surrounding anatomical neighbourhood. This review outlines the role of bone marrow immunohistology in the laboratory evaluation of patients with suspected and established plasma cell neoplasms and its emerging role in understanding myeloma biology for possible future therapeutic application.

Isolation, maturational level, and functional capacity of human colon lamina propria plasma cells

BACKGROUND AND AIMS

Large numbers of plasma cells (PC) localise in the intestinal lamina propria (LP) where they play a critical role in the defence against pathogens. This study analyses the level of maturation reached by normal human colon LPPC in comparison with that of bone marrow (BM) PC.

METHODS

A technique was designed to purify LPPC by combining collagenase digestion of the mucosal layer and immunomagnetic selection of CD54(+) LP cells. It provided highly purified PC, as demonstrated by morphology, CD38(h) phenotype, and cytoplasmic IgA staining criteria. This procedure allowed comparison of in vitro functional capacities and a broad phenotypic analysis of BMPC and LPPC.

RESULTS

LPPC and BMPC exhibited identical expression of differentiation markers (CD19(-/+), CD20(-), HLA-DR(low/-), VS38c(high)), survival molecules (CD95 (low/-), Bcl-2(+)), and B cell transcription factor profile, as well as similar in vitro Ig secreting kinetics (14 days) and lack of susceptibility to apoptosis by CD95 ligation. In contrast, they markedly differed in adhesion molecule expression, as LPPC showed higher levels of CD44 and CD21 and were alpha 4 beta 7(+) whereas BMPC lacked this integrin and expressed higher levels of CD49d and CD31.

CONCLUSION

These data indicate that PC at effector sites of the humoral response (BM and LP) show similar high differentiation, survival, and functional features but display a distinctive pattern of adhesion molecules, probably related to their respective homing locations.

The heterogeneity shown by human plasma cells from tonsil, blood, and bone marrow reveals graded stages of increasing maturity, but local profiles of adhesion molecule expression

Plasma cells (PCs) are the final B-cell differentiation stage. Recent evidence reveals relevant functional differences within the PC compartment. In rodents, early PCs formed in secondary lymphoid tissues show enhanced apoptosis and short life span, whereas PCs present in a final destination organ, such as the bone marrow (BM), have reached a stable prolonged survival state. BM PCs arrive at this organ as a circulating precursor whose cellular nature remains uncertain. An initial aim of this study was to characterize this circulating cell. We hypothesized that antibody-secreting cells detectable in the human blood after immunization might be a candidate precursor. These cells were obtained from the blood of volunteers immunized 6 days earlier with tetanus toxoid (tet), and they were unambiguously identified as PCs, as demonstrated by their expression of the CD38(h) phenotype, by morphology, by immunoglobulin (Ig) intracytoplasmic staining, and by IgG-tet-secreting capacity in vitro. In addition, by using the common CD38(h) feature, human PCs from tonsil (as a possible source of early PCs), from blood from tet-immunized donors (as the putative precursors of BM PCs), and from BM (as a deposit organ) have been purified and their phenotypes compared. The results show that a variety of differentiation molecules, proteins involved in the control of apoptosis, the B-cell transcription factors, positive regulatory domain I-binding factor 1/B lymphocyte-induced maturation protein 1 and B cell-specific activating protein and, at least partially, the chemokine receptor CXCR4 were expressed by human PCs following a gradient of increasing maturity in the direction: tonsil-->blood-->BM. However, PCs from these different organs showed a local pattern of adhesion molecule expression. These observations are discussed in light of the complex physiology of the human PC compartment.

Phenotypic characterization of five dendritic cell subsets in human tonsils

Heterogeneous expression of several antigens on the three currently defined tonsil dendritic cell (DC) subsets encouraged us to re-examine tonsil DCs using a new method that minimized DC differentiation and activation during their preparation. Three-color flow cytometry and dual-color immunohistology was used in conjunction with an extensive panel of antibodies to relevant DC-related antigens to analyze lin(-) HLA-DR(+) tonsil DCs. Here we identify, quantify, and locate five tonsil DC subsets based on their relative expression of the HLA-DR, CD11c, CD13, and CD123 antigens. In situ localization identified four of these DC subsets as distinct interdigitating DC populations. These included three new interdigitating DC subsets defined as HLA-DR(hi) CD11c(+) DCs, HLA-DR(mod) CD11c(+) CD13(+) DCs, and HLA-DR(mod) CD11c(-) CD123(-) DCs, as well as the plasmacytoid DCs (HLA-DR(mod) CD11c(-) CD123(+)). These subsets differed in their expression of DC-associated differentiation/activation antigens and co-stimulator molecules including CD83, CMRF-44, CMRF-56, 2-7, CD86, and 4-1BB ligand. The fifth HLA-DR(mod) CD11c(+) DC subset was identified as germinal center DCs, but contrary to previous reports they are redefined as lacking the CD13 antigen. The definition and extensive phenotypic analysis of these five DC subsets in human tonsil extends our understanding of the complexity of DC biology.

Analysis of MUM1/IRF4 protein expression using tissue microarrays and immunohistochemistry

The gene encoding MUM1 was characterized as a possible translocation partner in chromosomal abnormalities involving a significant number of multiple myelomas. The overexpression of the MUM1 protein as a result of translocation t(6;14) (p25;q32) identified MUM1 as a putative regulatory molecule involved in B-cell differentiation and tumorigenesis. The expression of MUM1 protein in multiple myelomas supports this hypothesis. In the current study, using tissue microarray technology, we have tested the expression of the MUM1 protein in 1335 human malignancies and normal tissues. Our data show that the MUM1 protein is expressed in a wide spectrum of hematolymphoid neoplasms and in malignant melanomas but is absent in other human tumors. In addition, in tissue microarrays as well as in conventional paraffin sections, MUM1 staining was found to lack specificity in detecting plasmacytic differentiation as compared with two markers, CD138/Syndecan and VS38, commonly used in paraffin immunohistochemistry for detection of plasma cells.

Plasmablastic lymphoma of the lung: report of a unique case and review of the literature

Non-Hodgkin lymphomas associated with acquired immunodeficiency syndrome are heterogeneous. Recently, a novel subtype of non-Hodgkin lymphoma occurring mostly in patients with acquired immunodeficiency syndrome has been described and designated as plasmablastic lymphoma. The histomorphologic and immunophenotypic findings of this distinct subtype of non-Hodgkin lymphoma have been characterized previously. Most patients present with oral cavity involvement. We report a case of plasmablastic lymphoma presenting as a lung tumor. To our knowledge, this is the first case report of this unusual subtype of diffuse large B-cell lymphoma in this location.

CD markers in pituitary adenomas

Immunostaining of CD markers in normal pituitary cells has been reported, but a study of these markers in pituitary adenomas has not been done. The expression of CD 3, CD 8, CD 15, CD 20, CD 30, CD 43, CD 45R0, CD 45 R, CD 79 alpha, and VS-38c was investigated in a collection of 65 pituitary adenomas of various types. CD 3 was present in 75%, CD 8 in 18.5%, CD 15 in 12.3%, CD 20 in 66.1%, CD 30 in 10.8%, CD 43 in 10.8%, CD 45 RO in 72.3%, CD 45 R in 16.9%, CD 79alpha in 0% and VS-38 c in 44.6%. Densely granulated GH cell adenomas expressed CD 3, CD 20, CD 45 RO, and CD 45 R, but no other markers. Sparsely granulated GH cell adenomas showed CD 3, CD 8, CD 20, CD 43, and CD 45 RO. Mixed GH/prolactin cell adenomas contained CD 3, CD 8, CD 20, CD 30, CD 45RO, CD 45 R, and VS-38c. Mammosomatotroph cell adenomas were positive only for CD 3, CD 8, CD 20, CD 43, and CD 45 RO. Prolactin cell adenomas expressed CD 3, CD 8, and CD 20. ACTH cell adenomas showed CD 3, CD 15, CD 20, CD 30, CD 45 RO, CD 45 R, and VS-38c. TSH cell adenomas contained CD 3, CD 8, CD 15, CD 20, CD 45 RO, and VS-38c. Gonadotroph cell adenomas were positive for CD 3, CD 8, CD 20, CD 45 RO, CD 45 R, and VS-38c. Alpha-subunit-only adenomas expressed CD 3, CD 8, CD 15, CD 20, CD 30, CD 45 RO, and VS-38c. Plurihormonal adenomas contained CD 3, CD 8, CD 20, CD 30, CD 43, CD 45 RO, CD 45 R, and VS-38c. Oncocytic adenomas were positive for all markers except CD 45 RA and CD 79 alpha. We conclude that the spectra of different adenoma types expressing CD markers varies greatly and that significant correlations do not exist, although noninvasive adenomas appear to express CDs more frequently than invasive adenomas. We have no clear-cut explanations for the various expressions and suggest that it may be a sign of local inter-actions between the immune system and pituitary adenomas.

Double immunofluorescence labelling of routinely processed paraffin sections

Double immunoenzymatic labelling of routinely processed human tissues has been used in many histopathology laboratories to compare the expression patterns of pairs of antigenic markers. However, these techniques are time-consuming, prone to background staining, and rarely suitable for detecting two antigens present at the same site, since one label tends to obscure the other. This paper reports the use of immmunofluorescence for double labelling of pairs of molecular markers in routinely processed tissue. The primary antibodies are either monoclonal reagents of differing isotype/subclass, or antibodies from different species, and labelling is visualized on a conventional fluorescence microscope equipped with a cooled CCD camera. Images can be captured and adjusted using personal computer hardware and software. This approach could be used for a wide range of tissue markers and only minimal tissue autofluorescence was observed. The procedure is more rapid than enzyme-based techniques and avoids the problems of interpreting two antigens present at the same site. Its establishment involves relatively minor expenditure and it may represent the optimal technical approach to the co-localization of pairs of antigens in routinely processed tissue samples.

Heparan sulfate proteoglycan isoforms of the CD44 hyaluronan receptor induced in human inflammatory macrophages can function as paracrine regulators of fibroblast growth factor action

The CD44 glycoprotein is expressed in multiple isoforms on a variety of cell types where it functions as a receptor for hyaluronan-mediated motility. Recently, interest has centered on CD44 heparan sulfate proteoglycan (HSPG) isoforms because of their potential to sequester heparin-binding growth factors and chemokines. Expression of these isoforms on ectodermal cells has recently been shown to regulate limb morphogenesis via presentation of fibroblast growth factor (FGF) 4/FGF 8 while expression on tumor cells was shown to sequester hepatocyte growth factor and promote tumor dissemination. To date, however, CD44 HSPG expression in tissue macrophages and lymphocytes has not been adequately investigated, despite the fact these cells actively synthesize growth factors and chemokines and indirect evidence that monocyte CD44 sequesters macrophage inflammatory protein-1beta. Here we show primary human monocytes rather than lymphocytes express CD44 HSPGs, but only following in vitro differentiation to macrophages or activation with the proinflammatory cytokine interleukin-1alpha or bacterial lipopolysaccharide. Furthermore, we show these isoforms are preferentially modified with heparan rather than chondroitin sulfate, bind the macrophage-derived growth factors FGF-2, vascular endothelial growth factor, and heparin-binding epidermal growth factor with varying affinities (K(d) 25-330 nM) and in the case of FGF-2, can stimulate productive binding to the high affinity tyrosine kinase FGF receptor 1 (FGFR1). In contrast, we find no evidence for significant binding to C-C chemokines. Last, we confirm by immunofluorescent antibody staining that inflamed synovial membrane macrophages express CD44 HSPGs and that expression is greatest in cells containing high FGF-2 levels. These results suggest a paracrine role for macrophage CD44 HSPG isoforms in the regulation of growth factor action during inflammation.

Nasopharyngeal tonsil's provision of the surface secretions with immunocytes, a property additional to antigen processing

As we recently found that IgA, IgM, and IgG are produced and secreted by immunocytes present in nasopharyngeal secretions, we tested the hypothesis that B- and T-lymphocytes in the surface secretions are derived from the nasopharyngeal tonsil in an active process. By immunohistochemistry, we found that numerous B- and T-lymphocytes were often accumulated in restricted areas in the epithelium, and some of these cells were demonstrated just beneath the epithelial surface or could be observed protruding into the lumen. A portion of these cells were Ki-67+, indicating clonal expansion and/or immunoglobulin class switching. Analyses of the surface secretions by immunocytochemistry also demonstrated B- and T-lymphocytes, as well as Ki-67+ cells--a finding that indicates that immunologically active cells are transported into the surface secretions. The results imply that there is a substantial migration from the nasopharyngeal tonsil of immunologically active cells into the surface secretions.

Electron microscopy in tumour diagnosis: continuing to complement other diagnostic techniques

The histopathological diagnosis of tumours has been transformed by immunohistochemistry. Used with experience and judgement, a panel of antibodies or antisera, combined when necessary with antigen retrieval, will enable the accurate typing of most problematic tumours. This has led many histopathologists to question whether the electron microscope has any residual utility for tumour diagnosis; the machines are large, costly to purchase and maintain, and will accept only minute samples of tissue. The following articles by Mierau and by Eyden, both strong advocates, comment on the current and future role of electron microscopy in tumour diagnosis.

Oral plasmablastic lymphoma in previously undiagnosed HIV disease

Non-Hodgkin's lymphoma is the second most common HIV-associated malignancy. This report details a case of the recently described entity plasmablastic lymphoma of the mouth in a patient who was later found to have severe HIV disease. The tumor manifested as a large ulcerated mass of the left maxillary alveolus, causing bony destruction and tooth mobility. Histologic examination of lesional tissue revealed a lymphoid tumor with a high proliferation rate containing lymphoplasmacytoid cells that were reactive to the plasma cell marker VS38c but not to CD20 or CD79a; these are features of the recently reported non-Hodgkin's lymphoma termed plasmablastic lymphoma. This is only the second report of an unusual tumor that has a predilection for the orofacial tissues.

Expression of VEGF in routinely fixed material using a new monoclonal antibody VG1

The aim of this study was to raise and characterize a monoclonal antibody reactive with VEGF (vascular endothelial growth factor) in routinely fixed specimens and to use it to investigate its tissue distribution in normal and pathological specimens. Recombinant VEGF 189 protein was used to raise a monoclonal antibody. The specificity of the antibody was confirmed using COS cells transfected with cDNA coding for VEGF 121, 165 and 189 protein and by western blotting studies. The resulting antibody VG1 was shown to react with the 121, 165 and 189 isoforms of VEGF protein in routinely processed material. In normal tissues, there was strong staining of endometrial and salivary glands and of the mucosa of the gastro-intestinal tract. In tumours, a proportion of the neoplastic cells in lung and breast cancer and in melanoma were labelled. In all tissues, whether normal or malignant, striking VEGF positivity was seen in plasma in vessels and stroma. This study has shown that antibody VG1 detects the 121, 165 and 189 VEGF isoforms in routinely fixed specimens. The results of the normal tissue and tumour labelling are in agreement with other studies using alternative methods of detection. This should be a useful and reliable reagent for studies of VEGF and angiogenesis in human pathological material.

Solitary extramedullary plasmacytoma in the retroperitoneum

Solitary extramedullary plasmacytoma is an uncommon neoplasm and occurs most frequently in the upper respiratory tract. Herein, we reported a solitary extramedullary plasmacytoma in the retroperitoneum. A 28-year-old man presented with obstructive jaundice and a retroperitoneal tumor. Ultrasound-guided biopsy confirmed that the lesion was a plasma cell neoplasm. A detailed investigation showed that no other sites were involved. The tumor got a moderate reduction following local irradiation, and a complete remission was achieved after 12 courses of adjuvant chemotherapy. Therefore, the possibility of a solitary extramedullary plasmacytoma should be considered in the differential diagnosis of obstructive jaundice without a history of multiple myeloma.

Expression of VS38 in osteoblasts and stroma cells of bone tumors

VS38 is a mouse monoclonal antibody which recognizes an intracytoplasmic antigen of 64 kilodaltons present in normal and neoplastic cells. It was reported to be of potential value in identifying myeloma or plasmacytoma in bone marrow or other tissues. During diagnostic analysis of bone marrow biopsies we noticed a consistent staining of osteoblasts with VS38. This led us to investigate the immunoreactivity in a range of bone lesions. 58 lesions were examined in the current study, including benign and malignant tumors as well as tumor like lesions and processes with reactive bone formation. The Streptavidin-peroxidase complex technique was applied on paraffin embedded sections, with 3-amino-9-ethylcarbazole serving as chromogen. All osteoblasts of reactive origin and part of the osteoblasts of benign neoplasms showed positive immunostaining. The antibody stained stroma cells in 81.25% (13/16) of the cases of benign osteogenic tumors and in 82.35% (14/17) of the osteosarcomas. Additionally, VS38 labelling was observed in bone tumors of fibrohistiogenic origin such as nonossifying fibroma and giant cell tumor, the histogenesis of which is still being debated. On the whole, it can be concluded that antibody VS38 lacks specificity as a plasma cell marker. It shows, however, a striking affinity to osteoblasts and in part also to stroma cells of osteogenic and fibrohistiogenic bone tumors.

Epstein-Barr virus in B-cell lymphomas associated with chronic suppurative inflammation

Chronic antigenic stimulation is considered to play an important role in neoplastic lymphoid transformation. This paper describes three cases of non-Hodgkin lymphomas (NHLs) associated with long-standing chronic suppuration. Two were primary bone lymphomas associated with long-standing chronic osteomyelitis and one was a primary skin lymphoma associated with chronic venous ulcers with a latent period of 13 years. All were diffuse large B-cell lymphomas, with plasmacytoid differentiation in two cases. Epstein-Barr virus (EBV)-encoded RNAs were demonstrated in virtually all tumour cells in all cases by in situ hybridization. Immunohistochemistry revealed EBV-encoded latent membrane protein (LMP)-1 expression in one case and BZLF1 protein expression in all three cases, whilst the EBV-encoded nuclear antigen (EBNA)-2 was not detected. Kaposi's sarcoma-associated herpesvirus (KSHV) sequences were absent in two cases studied. Our cases show similarities with pyothorax-associated pleural lymphomas reported mainly from Japan and recently from France, which are invariably associated with EBV. These findings suggest a causal effect of EBV in the development of this type of lymphoma complicating long-standing chronic suppuration. Localized immunodepression induced by chronic inflammation or immunosuppressive cytokines may favour the clonal proliferation of EBV-infected B cells.