Accuracy of diagnosis of malignant lymphoma by combining fine-needle aspiration cytomorphology with immunocytochemistry and in selected cases, Southern blotting of aspirated cells: a tissue-controlled study of 86 patients

Fine-needle aspiration (FNA) cytology of lymph nodes in malignant lymphoma is fraught with difficulty. In certain clinical situations, cytology has been documented to be useful in patients with malignant lymphoma. The intent of our investigation was to determine the accuracy of a multiparameter approach in diagnosing lymphoma. We reviewed the results of FNA cytology combined with the immunocytochemistry and, in some cases, the Southern blots of aspirated cell suspensions obtained from 86 suspected lymphoma patients who subsequently underwent surgical biopsy of the aspirated site. In four cases, in which FNA was unable to retrieve sufficient material for diagnosis, the histology showed extensive fibrosis. When the FNA diagnoses were compared with the histologic diagnoses, the diagnosis concurred in 69 cases (56 malignant lymphomas, 12 reactive, 1 atypical lymphoid proliferation). There was one false-positive, six false-negatives, and eight cases diagnosed as atypical lymphoid proliferation. Overall accuracy was 91%. There were two types of false-negative cases: those in which a diagnosis of another malignancy or unspecified malignant neoplasm was made and those that were diagnosed as reactive when the histology showed lymphoma. In seven cases, the DNA rearrangement studies of the antigen receptor genes were successfully performed on the aspirated cells and were useful in establishing lineage and clonality of both B and T lymphoid cells. Our study indicated that the use of a multiparameter approach in the diagnosis of malignant lymphoma by FNA enhanced the accuracy of diagnosis of the non-Hodgkin's lymphomas. In Hodgkin's disease, no benefit was derived from the approach.

8;20 chromosomal translocation in a case of acute leukemia. Cytogenetic, immunophenotypic, ultrastructural, and molecular characteristics

An 8;20 chromosomal translocation was observed in the leukemia cells of a 3-year-old girl. To our knowledge, this is the first report of this translocation in de novo acute leukemia. This chromosomal defect was present in the leukemia cells at diagnosis and also at relapse, but remission bone marrow cells had the 46,XX karyotype. By morphologic and cytochemical criteria the leukemia was myeloid but these features were more lymphoid when the leukemia recurred. However, the immunophenotype was consistent with myeloid leukemia and did not change at relapse. No evidence for either immunoglobulin or TCR gene rearrangement was observed.

Fludarabine: a new agent with marked cytoreductive activity in untreated chronic lymphocytic leukemia

Thirty-three patients with chronic lymphocytic leukemia (CLL) with advanced Rai stage (III-IV) or progressive Rai stage (0-II) disease were treated with fludarabine as a single agent. Eleven patients (33%) obtained a complete remission (CR), 13 (39%) a clinical CR with residual nodules as the only evidence of disease (nodular partial remission [PR]), and two patients (6%) achieved a PR for a total response rate of 79%. Response was rapid, usually occurring after three to six courses of treatment. The major morbidity was infection. Febrile episodes occurred in 13% of the courses (pneumonia 6%, minor infection 4%, and transient fever of undocumented cause 3%). Fludarabine appears to be the most cytoreductive single agent so far studied in CLL.

Strategy for breakpoint cluster region analysis in chronic myelocytic leukemia in a routine clinical laboratory

Despite the increasing reliance on breakpoint cluster region (bcr) determinations in diagnosis of chronic myelocytic leukemia (CML), few reports have dealt with the practical aspects of specimen analysis. In the setting of a routine molecular diagnostics laboratory, samples from 68 patients with active CML were evaluated for bcr rearrangements, with the use of a variety of enzymes and two probes. The data have been used to develop an efficient strategy for bcr screening and breakpoint determination. Screening with the universal bcr (UBCR) probe on Xba I and BgI II digests yielded bcr rearrangements in 100% of the Ph1-positive patients and three of the seven Ph1-negative patients, giving bcr analysis a sensitivity of 100%. A single-enzyme screen using the UBCR probe would have resulted in a false negative rate of 10%. The false negative rate was determined during the breakpoint site analysis from additional digests hybridized to both the 3' and UBCR probes. The false negative rate for the 3' probe was 26.5%, because of deletions or 5' rearrangements. The method of breakpoint site determination was dependent on screening results. In 78% of cases, one additional hybridization with two enzyme digests was required. During breakpoint site analysis, a rare false negative result was also demonstrated with Bam HI and Eco RI. This screening strategy has made bcr analysis competitive with cytogenetic analysis at the authors' institution; although turnaround time may be slightly longer, bcr analysis can yield information (such as detecting bcr-positive/Ph1-negative patients and determining breakpoint site) that cannot be obtained by cytogenetics.

Myeloid surface antigen-positive acute lymphoblastic leukemia (My+ ALL): immunophenotypic, ultrastructural, cytogenetic, and molecular characteristics

Leukemic blasts from 40 consecutively admitted adults with untreated acute lymphoblastic leukemia (ALL) were examined for myeloid surface antigen expression. Of these, 14 (35%) were reactive with one or more myeloid monoclonal antibodies. Each example of myeloid surface antigen-positive (My+ ALL) met the standard morphologic and cytochemical criteria for ALL. In addition, none of the 13 samples studied for ultrastructural evidence of myeloperoxidase met the criteria for acute myelocytic leukemia (AML). All patient samples reacted with lymphoid monoclonal antibodies: CD10+ (8 patients), CD19+ CD10- (2 patients), T cell+ (2 patients), and T cell+ CD10+ (2 patients). Coexpression of myeloid and lymphoid determinants was established by two-color immunofluorescence studies using flow cytometry in five of five samples analyzed. Cytogenetic abnormalities that have been associated with myeloid and mixed leukemias were common, including t(9;22), 7q-, abnormalities of 11q with or without a translocation, 20q-, and -5. Blasts from seven patients were studied at the molecular level. Immunoglobulin heavy chain gene rearrangements were detected in five of five samples with B cell+ T cell- phenotypes. One sample that was T cell+ CD10+ was germline for the immunoglobulin heavy chain and the T cell receptor gamma- and beta-chain genes. The other patient with T cell+ CD10+ blasts relapsed with AML following allogeneic bone marrow transplantation. The leukemia cells at the time of diagnosis and the cells at relapse demonstrated similar cytogenetics and the same immunoglobulin gene rearrangement, suggesting a clonal relationship. As a group, the My+ ALL patients had a significantly decreased complete remission rate when compared to My- ALL patients. Further studies at the molecular level will be required to determine the significance of karyotype abnormalities in My+ ALL.

Molecular heterogeneity in acute leukemia lineage switch

Six cases of acute leukemia that underwent lineage switch from acute lymphocytic leukemia to acute myelogenous leukemia are reported. The mean age of the patients was 24 years, time to conversion was 36 months, and survival after conversion was only 3 months. Of the three cases which showed abnormal metaphases at both diagnosis and conversion, two (cases 2, 5) showed related cytogenetic abnormalities, and the third showed (case 3) independent chromosomal changes. Molecular analysis for immunoglobulin heavy chain and T-cell receptor beta chain genes showed that five of the six cases had rearrangement of at least one of these lymphoid associated genes at conversion to acute myelogenous leukemia. The single case (case 3) in which there were no lymphoid gene rearrangements at conversion was also the only case in which independent karyotypic abnormalities at diagnosis and conversion were demonstrated. Our findings suggest that lineage switch can represent either relapse of the original clone with heterogeneity at the molecular level or the emergence of a second new leukemic clone without molecular heterogeneity.

Therapy of lymphoid and undifferentiated chronic myelogenous leukemia in blast crisis with continuous vincristine and adriamycin infusions plus high-dose decadron

Thirty patients with Philadelphia chromosome-positive lymphoid (20 patients) or undifferentiated (ten patients) chronic myelogenous leukemia in blast crisis were treated with 0.4 mg of vincristine by continuous intravenous infusion (CIV) daily for 4 days; (doxorubicin) 12 mg/m2 of Adriamycin (Adria Laboratories, Columbus, OH) by continuous intravenous infusion daily for 4 days; and 40 mg of decadron daily on days 1 through 4, 9 through 12, and 17 through 20 (VAD). Course 2 was given starting on day 24 with the addition of cyclophosphamide 1 g/22. Overall nine patients achieved complete remission (30%) and three attained a partial remission (10%), for an overall response rate of 40%. Four patients expired during induction whereas 14 had resistant disease. Response rate was significantly higher for patients with lymphoid compared to undifferentiated morphology (55% versus 10%; P = 0.05). In lymphoid blast crisis, Calla-positive disease was associated with a higher response rate compared to Calla-negative disease (75% versus 25%; P = 0.08). Eleven patients developed infections, and seven had fever without documented infections. The median overall survival was 29 weeks. Median survival was 43 weeks for patients achieving complete remission and 20 weeks for those with resistant disease. Remission duration was 39 weeks. After primary and salvage therapy, nine patients are alive, six of them in continuous remission for 19+ to 112+ weeks. The authors conclude that VAD chemotherapy is an effective regimen with acceptable toxicity in patients with lymphoid blast crisis especially those with Calla-positive disease. Alternate induction regimens for undifferentiated disease and for maintenance therapy are currently being investigated.

Infectious mononucleosis. The spectrum of morphologic changes simulating lymphoma in lymph nodes and tonsils

Lymph-node and tonsillar biopsies occasionally are obtained from patients with the infectious mononucleosis syndrome secondary to Epstein-Barr viral infection, particularly if the clinical presentation is atypical and a viral etiology is not suspected. The presence of Reed-Sternberg-like cells in infectious mononucleosis resulting in confusion with Hodgkin's disease is well-known; however, similar difficulty in excluding a non-Hodgkin's lymphoma can be encountered. Eleven cases of reactive lymphoid hyperplasia with the morphologic features of infectious mononucleosis are reported, nine of which had documented Epstein-Barr viral infection. The spectrum of morphologic changes associated with Epstein-Barr viral infection is discussed, with emphasis on the features that permit their distinction from non-Hodgkin's lymphoma. Morphologic features mimicking lymphoma included extensive immunoblastic proliferations in sheets and nodules and marked cytologic atypia. Hodgkin's disease was simulated by the tendency in some cases for the atypical Reed-Sternberg-like cells to cluster about necrotic foci and to show pronounced cytologic atypia. Features permitting the distinction from non-Hodgkin's lymphoma included persistent reactive foci with the classic features of infectious mononucleosis, a polymorphous background of transformed lymphocytes rather than irregular or twisted lymphoid cells as seen in non-Hodgkin's lymphoma, and preservation of underlying reticulin architecture rather than destruction, even in cases with extensive immunoblastic proliferation. Hodgkin's disease was excluded by requiring strict criteria for Reed-Sternberg cells and noting the reactive background as inconsistent with Hodgkin's disease. Immunoperoxidase staining of seven of the cases with anti-Leu-M1 failed to demonstrate immunoreactivity of the Reed-Sternberg-like cells with this monoclonal antibody.

The morphologic classification of acute lymphoblastic leukemia in childhood. Observations on concordance using a simple scoring system

The French-American-British (FAB) cooperative group proposed a simple scoring system in 1981 to improve concordance among researchers and clinicians for the subclassification of acute lymphoblastic leukemia (ALL) into subtypes L1 and L2. The authors subtyped 50 consecutively admitted patients with common ALL of childhood according to the FAB scoring system to assess concordance among a member of the FAB group (J.B.) and two pathologists (S.S. and C.C.) who are not FAB members. The initial agreement of 66% was unsatisfactory to the authors prompting the critical evaluation of the major sources of disagreement. Concordance was improved greatly by the use of two technics that are logical extensions of the scoring system: performing 100-200 differential cell counts to determine the correct percentages in borderline cases, and using reference drawings that illustrate blasts with cytoplasmic contents of 15%, 20%, and 25% in determining the cell's nuclear cytoplasmic ratio. The authors believe that the criteria explicitly given greater weight by the FAB scoring system (nuclear cytoplasmic ratio and nucleoli) are the most subjective. By following the criteria carefully and resolving differences together at a multiheaded microscope, a concordance of 92% was achieved.

Biphenotypic lymphoblastic lymphoma. An unusual tumor with lymphocytic and granulocytic differentiation

An unusual example of a lymphoblastic lymphoma with evidence of both T-lymphocytic (Leu-1, Leu-2, Leu-3, OKT-6, terminal transferase-positive) and immature granulocytic (Mo1, chloroacetate esterase, lysozyme, alpha-1-antitrypsin-positive) cell proliferations was studied. The tumor arose in the oropharynx of a 39-year-old man without evidence of blood or bone marrow involvement. This tumor has been termed a "biphenotypic lymphoblastic lymphoma," and the origin of which appears to be from uncommitted progenitor cells capable of both lymphoid and myeloid differentiation. Biphenotypic lymphoblastic lymphomas, like biphenotypic leukemias, may occur more commonly than is appreciated, and may account for reported cases of acute myeloblastic leukemia after lymphoblastic lymphoma.

Pancreatic choriocarcinoma presenting as inflammatory pseudocyst

A primary pancreatic choriocarcinoma was discovered at surgery in a patient with a clinical diagnosis of pancreatic inflammatory pseudocyst. To our knowledge, this is the first example of an extragonadal choriocarcinoma reported as a primary at this site. We consider this neoplasm to be another example of a visceral choriocarcinoma arising from a primary carcinoma through a process of metaplasia. This case illustrates the inherent difficulties in the preoperative evaluation of cystic lesions of the pancreas, and the importance of recognizing endocrinologic manifestations of malignant disease.