The role of splenectomy in management of splenic B-cell lymphomas

INTRODUCTION

Splenic B-cell lymphomas are rare and understudied entities. Splenectomy is frequently required for specific pathological diagnosis in patients with splenic B-cell lymphomas other than classical hairy cell leukemia (cHCL), and can be effective and durable therapy. Our study investigated the diagnostic and therapeutic role of splenectomy for non-cHCL indolent splenic B-cell lymphomas.

METHODS

Observational study of patients with non-cHCL splenic B-cell lymphoma undergoing splenectomy between 1 August 2011 and 1 August 2021 at the University of Rochester Medical Center. The comparison cohort was patients categorized as having non-cHCL splenic B-cell lymphoma who did not undergo splenectomy.

RESULTS

Forty-nine patients (median age 68 years) had splenectomy (SMZL n = 33, HCLv n = 9, SDRPL n = 7) with median follow up of 3.9 years post splenectomy. One patient had fatal post-operative complications. Post-operative hospitalization was ≤ 4 days for 61% and ≤ 10 days for 94% of patients. Splenectomy was initial therapy for 30 patients. Of the 19 patients who had previous medical therapy, splenectomy changed their lymphoma diagnosis in 5 (26%). Twenty-one patients without splenectomy were clinically categorized as having non-cHCL splenic B-cell lymphoma. Nine required medical treatment for progressive lymphoma and of these 3 (33%) required re-treatment for lymphoma progression compared to 16% of patients following first line splenectomy.

CONCLUSION

Splenectomy is useful for the diagnosis of non-cHCL splenic B-cell lymphomas with comparable risk/benefit profile and remission duration to medical therapy. Patients with suspected non-cHCL splenic lymphomas should be considered for referral to a high-volume center with experience in performing splenectomies for definitive diagnosis and treatment.

[Splenic diffuse red pulp small B-cell lymphoma diagnosed by splenectomy initially mimicking hairy cell leukemia-Japanese variant]

A 62-year-old man presented to the hospital with thrombocytopenia, and splenomegaly was detected. His blood films prepared by natural air drying revealed medium-sized lymphocytes with unevenly distributed large and small villous projections. The cytoplasm was basophilic, nuclei were oval with clumped chromatin, and nucleoli were absent in most cells. Immune phenotypes CD19+, CD20+, CD11c+, FMC7+, IgM+, and Igκ+ were detected. TRAP stain appeared negative, IgH JH chain genes were monoclonally rearranged, and BRAF V600E mutation was not detected. On the basis of these findings, hairy cell leukemia-Japanese variant (HCL-JV) was strongly suspected. The patient was followed up for >4 years without treatment. However, because thrombocytopenia and splenomegaly gradually progressed, splenectomy was performed. Microscopic examination confirmed that the splenic white pulp was atrophic. Moreover, infiltrates comprising small-to-medium-sized atypical lymphocytes with inconspicuous nucleoli were predominantly detected in the congested red pulp. On the basis of these results and immune histochemical findings, the patient was diagnosed with splenic diffuse red pulp small B-cell lymphoma (SDRPL). Here we discussed whether the aforementioned diseases (HCL-JV and SDRPL) are the same; however, further accumulation of cases is essential to draw a definite conclusion.

Multiple opportunistic infections after high-dose steroid therapy for giant cell arteritis in a patient previously treated with a purine analog

We present the case of a 74-y-old HIV-negative female who suffered simultaneously from multiple opportunistic infections and a Klebsiella pneumoniae sepsis during high-dose steroids for giant cell arteritis. The patient was treated with a purine analog due to hairy cell leukaemia 10 y previously. Purine analog therapy can lead to long lasting defects in cell-mediated immunity. In these patients, treatment with steroids should be closely monitored with CD4 counts.

B-cell-activating factor inhibits CD20-mediated and B-cell receptor-mediated apoptosis in human B cells

B-cell-activating factor (BAFF) is a survival and maturation factor for B cells belonging to the tumour necrosis factor superfamily. Among three identified functional receptors, the BAFF receptor (BAFF-R) is thought to be responsible for the effect of BAFF on B cells though details of how remain unclear. We determined that a hairy-cell leukaemia line, MLMA, expressed a relatively high level of BAFF-R and was susceptible to apoptosis mediated by either CD20 or B-cell antigen receptor (BCR). Using MLMA cells as an in vitro model of mature B cells, we found that treatment with BAFF could inhibit apoptosis mediated by both CD20 and BCR. We also observed, using immunoblot analysis and microarray analysis, that BAFF treatment induced activation of nuclear factor-kappaB2 following elevation of the expression level of Bcl-2, which may be involved in the molecular mechanism of BAFF-mediated inhibition of apoptosis. Interestingly, BAFF treatment was also found to induce the expression of a series of genes, such as that for CD40, related to cell survival, suggesting the involvement of a multiple mechanism in the BAFF-mediated anti-apoptotic effect. MLMA cells should provide a model for investigating the molecular basis of the effect of BAFF on B cells in vitro and will help to elucidate how B cells survive in the immune system in which BAFF-mediated signalling is involved.

Marrow biopsy in the diagnosis of pyrexia of undetermined origin

Marrow from 62 cases of pyrexia of undetermined origin was examined cytologically, histologically, and bacteriologically. Diagnostic findings were present in five cases (8%), but all these patients presented definite clinical or haematological indications for marrow biopsy. It is concluded that marrow examination is useful in the diagnosis of pyrexia of undetermined origin but that cases for study must be selected in the light of general principles. Fever alone, even though prolonged and undiagnosed, is not an indication for marrow biopsy.

[Polyclonal B-cell lymphocytosis with clinical and hematological features resembling hairy cell leukemia]

A 49-year-old man was admitted to our hospital for investigation of splenomegaly and lymphocytosis. He had no significant past history and was not a smoker. Physical examination revealed massive splenomegaly and no palpable superficial lymph nodes. Hematological examination showed a hemoglobin concentration of 10.5g/dl, a platelet count of 9.8 x 10(4)/microliter, and a leukocyte count of 21.2 x 10(3)/microliter with 70% abnormal lymphocytes. In May-Giemsa stained blood films, the abnormal lymphocytes had round nuclei, abundant, pale cytoplasm, and slightly serrated edges. Phase-contrast microscopic and scanning electron microscopic examinations revealed many long surface villi. Tartrate-resistant acid phosphatase activity in these cells was negative. The abnormal lymphocytes had a CD5-, CD10-, CD11a+, CD11c+, CD19+, CD20+, CD22+ phenotype. These features were similar to those described for a variant form of hairy cell leukemia (HCL-Japanese variant). However, studies of Ig gene rearrangement and expression of sIg revealed a polyclonal proliferation of B cells. On the basis of these findings, this case was diagnosed as hairy B-cell lymphoproliferative disorder, a recently described condition characterized by polyclonal B-cell lymphocytosis and features resembling HCL-Japanese variant. Serological assays for antibodies against Epstein-Barr virus suggested a past infection. Splenectomy alleviated the anemia and thrombocytopenia, but not the lymphocytosis.

PROGRESSIVE MULTIFOCAL LEUCOENCEPHALOPATHY AND PRIMARY HYPERSPLENISM. WITH A NOTE ON THE ASSOCIATION BETWEEN DISEASE OF THE RETICULOENDOTHELIAL SYSTEM AND PROGRESSIVE MULTIFOCAL LEUCOENCEPHALOPATHY

A patient with progressive multifocal leucoencephalopathy was found to have primary hypersplenism, a benign disorder of the reticuloendothelial system. He failed to respond to conventional doses of corticosteroids. The clinical and pathological manifestations of his illness are described, and the development of the histopathological changes in the nervous system is discussed. Consideration of available data on progressive multifocal leucoencephalopathy reveals a striking association with disease of the reticuloendothelial system, the significance of which is discussed in relation to aetiology and treatment.

PATHOLOGY OF TUMOURS IN CHILDREN

An analysis of the types of tumour in children in the Manchester hospital region indicates that approximately two-thirds arose in the reticuloendothelial or nervous systems. The high mortality is largely due to the nature or site of the tumours, the majority of which cannot be eradicated by purely local measures. The most likely means of causing any significant improvement would be by greater centralization in the treatment of these children.

IgD class switching: identification of a novel recombination site in neoplastic and normal B cells

IgD on normal B lymphocytes usually is co-expressed with IgM. A minority of normal plasma cells and rare B cell malignancies express exclusively IgD (IgM-IgD+). The low frequency has been explained by the lack of a recognizable switch region within the C mu-C delta intron. We analyzed four cases of IgM-IgD+ hairy cell leukemia (HCL) by Southern (DNA) blot analysis and identified two cases with a recombinatorial event within the C mu-C delta intron and deletion of C mu. DNA sequence analysis of junctional regions showed that S mu or the immediate upstream region was used as a donor site and that the C mu-C delta intronic sigma delta region was used as acceptor site. Using polymerase chain reaction, we subsequently analyzed whether similar S mu-sigma delta recombinations occur in normal tonsils containing IgM-IgD+ plasma cells. Multiple products with a size range of 200-800 base pairs were detected in all four individuals, suggesting clustering of acceptor sites within sigma delta. Sequence analysis of three cloned products showed S mu-sigma delta recombinations similar those observed in HCL. The sigma delta region contains a relatively high content of pentameric repeats with an extremely G-rich area and appears to function as a vestigial switch recombination site in normal and neoplastic IgM-IgD+ B cells.

Recurrent hairy cell leukemia during pregnancy: a case report

Recurrent hairy cell leukemia was diagnosed during the second trimester of pregnancy, which was subsequently terminated because of therapeutic considerations. Treatment issues are discussed.

Human major histocompatibility complex class II invariant chain is expressed on the cell surface

Class II major histocompatibility complex antigens are intracellularly associated with a nonpolymorphic polypeptide referred to as the invariant chain. Before the class II heterodimer appears on the cell surface, the invariant chain dissociates but it has so far been unclear as to whether or not a proportion of the invariant chain also appears on the plasma membrane. We describe a study with three monoclonal antibodies which recognize an extracytoplasmic determinant present on all forms of the invariant chain and use them to demonstrate its presence on the surface of the intact cells. The determinants recognized by two of the antibodies were found to be located within the 60 amino acids at the extreme C-terminal (extracytoplasmic) end of the invariant chain. The invariant chain-specific monoclonal antibody, VIC-Y1, was found to bind a determinant located between amino acids 1 and 73, which correspond to mainly cytoplasmic residues. Using the C-terminal specific antibodies, the number of antibody binding sites on the surface of two B lymphoma lines was estimated to be 10(5) per cell. The results of this study appear to resolve the highly disputed question of whether or not the invariant chain can appear as a plasma membrane protein. The results are discussed in the context of a possible role for the invariant chain in antigen processing and presentation.

Persistent replication of herpes simplex virus type 1 in JOK-1 cells

Infection of the human B cell line JOK-1 with herpes simplex virus type 1 persisted over a period of more than 12 months (to date). Although limited cytopathic effects were seen, viral infection did not lead to extinction of the culture. Infectious centre assays, performed at various times after infection, revealed that only a small proportion of cells (1 to 10%) produced infectious virus particles. However, immunofluorescence studies showed that at any given time considerably more cells than calculated by infectious centre assays contained the immediate early viral protein ICP4 and expressed viral glycoproteins. These observations were confirmed by in situ hybridization analyses which revealed the presence of viral DNA even in cells not producing infectious particles. Since no evidence for the involvement of interferon could be found, some other so far unknown intrinsic property of the cells must be responsible for the restriction of virus replication and/or maturation.

Diversity in inhibitory effects of IFN-gamma and IFN-alpha A on the induced DNA synthesis of a hairy cell leukemia B lymphocyte clone reflects the nature of the activating ligand

A hairy cell leukemia population was used as a clonal model for studying the direct immunomodulatory effects of recombinant interferon-alpha A (rIFN-alpha A) and rIFN-gamma on human B-cell proliferation. The leukemic cell population KON was notably quiescent when incubated in medium alone but was induced to significant in vitro DNA synthesis when cultured with any of four activators of human B cells: anti-IgM antibody, Staphylococcus aureus cells (SAC), phorbol myristate acetate (PMA), or B-cell growth factor (BCGF). While both rIFN-gamma and rIFN-alpha A exhibited suppressive effects on these responses, their inhibitory patterns were distinct and reciprocal. Thus, rIFN-gamma exclusively suppressed anti-IgM-and SAC-induced leukemic DNA synthesis, and rIFN-alpha A significantly suppressed only PMA- and BCGF-induced DNA synthesis. The effects of the rIFN preparations were ablated in the presence of IFN type-specific monoclonal antibodies. Kinetic analyses and pulsing studies revealed that inhibition was most notable when cells were exposed concomitantly to IFN and the activating ligand. That the diverse effects of IFN-gamma and IFN-alpha A are manifested on a single B-cell clone was confirmed by Southern blot analysis of restriction enzyme-digested KON cell DNA with a JH-specific probe. These studies suggest that the therapeutic potential of the two types of IFN may be influenced by the nature of the extracellular ligands in the leukemic mileau that promote leukemic clonal expansion.

Induction of plasmacytoid and hairy cell features by phorbol esters (TPA) in B-lymphoma cells: attempted correlation with disease activity

Mononuclear cells concentrated from the blood of 16 non-Hodgkin's lymphoma (NHL) patients in the leukemic phase, were exposed to 10 ng/ml of TPA in an attempt to induce differentiation. Immunoglobulin (Ig) secretion, surface markers (SmIg, GP-70), tartrate resistant acid phosphatase (TRAP) and surface features were followed for up to six days in vitro. TPA induced 'hairy cell' like features in NHL cells as defined by cell morphology, ultrastructure, cell surface markers and the presence of TRAP. Unlike the results obtained in patients with CLL, cells from different patients at the same stage of disease reacted in a similar way. Differences were evident between NHL mononuclear cells obtained from patients in partial remission and active disease when compared with those derived from patients in complete remission. In the former group, NHL cells were maximally induced by TPA to secrete Ig and higher proportions of TRAP positive cells. In addition hairy cell features as seen by light and scanning electron microscopy were also more pronounced. TPA also induced the maximal expression of SmIg and GP-70 in cells derived from patients in this group. Patients with NHL in leukemic phase in complete remission did not express surface membrane GP-70 before or after TPA treatment while SmIg was expressed to some degree before TPA treatment and further induced following treatment with TPA. GP-70 appears to be a more reliable marker for follow-up of NHL patients than any other marker studied here.

Identification of p26Xb and p24Xb of human T-cell leukemia virus type II

Human T-cell leukemia virus type II (HTLV-II) isolated from a T-cell variant of hairy cell leukemia contains gag, pol and env genes as well as a fourth gene termed X, which can code three major open reading frames Xa, Xb and Xc. Proteins with molecular masses of 26 kDa (p26Xb) and 24 kDa (p24Xb) encoded by the Xb open reading frame were identified with antisera directed against synthetic peptides corresponding to the N-terminal and C-terminal amino acid sequences deduced from the structure of the Xb open reading frame. More than half the Xb products were found to be located in the nuclear fraction of HTLV-II-infected cells.

Hairy cell leukemia associated with carcinoma: report of two patients and review of the literature

The association of carcinoma and hairy cell leukemia (HCL) in two patients is recorded. One of the cases was a 58-year-old male who developed carcinoma of the kidney, while the second patient was a 48-year-old woman with carcinoma in the breast. This rare association is probably coincidental, as it is not described in most of the larger reported series of patients with HCL. It is of interest to note that the first patient had received radiation therapy thirty years before the diagnosis of HCL and carcinoma was made.

Differential effect of TPA and n-butyrate on induction of Ii and EBV antigens in the P3HR-1 lymphoblastoid cell line

The aim of this study was to test whether EBV induction by TPA or n-butyrate was related directly to hyperexpression of Ii, an electrophoretically invariant, 35 000 dalton, HLA-DR antigen-associated glycoprotein which is abundantly detected in EBV freshly transformed cells and is enhanced by EBV superinfection of lymphoblastoid cell lines. P3HR-1 lymphoblasts were treated with n-butyrate or TPA in variable doses and durations. The augmented expression of Ii, EBV antigens (EA and VCA), DNA synthesis, and cell growth and viability were monitored. n-Butyrate induced hyperexpression of Ii at 2 days with a maximal effective dose of 4 mM, induced EBV antigens (EA and VCA) in 36 per cent of the cells at 2 days, inhibited DNA synthesis and cell growth, and was not cytolytic at 48 h when Ii induction was maximal. TPA did not induce hyperexpression of Ii, induced EBV antigens (EA) in 30 per cent of the cells at 4 days, did not inhibit DNA synthesis and cell growth, and was not cytolytic in the time course and doses studied. Ii expression, therefore, did not appear to be an obligatory consequence of EBV antigen induction. Ii induction might be related to an effect of EBV inducers on cellular DNA synthesis, or on control of the cell cycle, or directly upon Ii gene regulation.

Human leukemia cell line K562 responds to erythroid-potentiating activity

We report that erythroid-potentiating activity (EPA), known to stimulate the proliferation of normal human erythroid precursors in vitro, has a growth-promoting effect on human K562 erythroleukemia cells and Friend mouse erythroleukemia cells. Detailed studies were carried out using an EPA produced by a human T-lymphoblast line (Mo). Although EPA has not been purified to homogeneity, several observations indicate that the factor elaborated by Mo cells that stimulates erythroleukemia cell growth is the EPA molecule. The erythroleukemia growth factor cofractionates with EPA using gel exclusion chromatography, isoelectric focusing, and ion exchange chromatography. In addition, the activities exhibit similar kinetics of heat inactivation. A granulocyte-macrophage colony-stimulating factor also elaborated by Mo cells had no effect on the growth of the erythroleukemia cells. Other sources of EPA, such as peripheral blood leukocyte-conditioned medium, preparations from urine of anemic patients, and medium conditioned by a human monocyte-like cell line, stimulated erythroleukemia cell growth. Mouse sources of EPA (termed "burst-promoting activity") stimulated mouse but not human erythroleukemia cells. The availability of cell lines apparently responsive to EPA should prove useful for examining the mode of action of this regulator of erythropoiesis.

[Splenectomy. Medical and surgical indications (observations on 95 cases)]

95 splenectomies carried out at the General Surgery Division of the Busto Arsizio Circolo Hospital between 1967 and 1977 are reported. After some brief historical notes, stress is laid on those forms of primary or secondary splenopathy which are receptive to surgical intervention. Splenectomies with surgical indication (traumatic ruptures during other operations for various conditions) are distinguished from those with medical indication: Cooley, Werlhoff, Hodgkin, hair cell leukaemia, Banti. The clinical, haematological and physiopathological aspects responsible for splenic change are considered for each individual disease on the basis of personal experience.