Localised extranodal lymphoma of the head and neck: the Sheffield Lymphoma Group experience (1971-2000)

AIMS

Over the 30-year period from 1971-2000, 3750 cases of lymphoma were referred to the Sheffield Lymphoma Group for investigation and treatment. Of these, 580 were extranodal presentations and, of these, 190 (33%) were localised to the head and neck region. The aim of this lymphoma database review was to evaluate the patient characteristics and survival rates for these patients.

MATERIALS AND METHODS

The sample included 98 women and 92 men, with a median age at presentation of 65 years.

RESULTS

The most common site affected was tonsil (34%), followed by salivary glands (16%). Other common sites were the thyroid, orbit and nasopharynx. The most frequent presenting feature was a swelling or mass, with pain, dysphagia and nasal obstruction also comprising large groups. All cases were non-Hodgkin's lymphoma. Fifty-five cases were histological grade 1; 132 were grade 2. Diffuse large B cell was the most common histological subtype. The overall 5- and 10-year survival rates were 55% (95% CI 47-62) and 44%, (95% CI 36-53), respectively, with a median survival of 92 months (95% CI 56-128). Stage and grade were both found to influence survival.

CONCLUSION

This data concords with and extends information available from previous studies. More detail is now required on specific head and neck sites.

The Sheffield nose--an occupational disease?

We report a case of silver tattooing of the nasal mucosa in a silver polisher. The concern in such cases is mainly due to the suspicion of melanoma. The diagnosis was confirmed by using the Laser Ablation Inductively Coupled Plasma Mass Spectrometry (LA-ICP-MS) method, which revealed the presence of two types of silver isotopes, at 107 and 109 m/z.

Peripheral T cell lymphoma: The Sheffield Lymphoma Group experience (1977-2001)

Peripheral T-cell lymphomas (PTCL) account for approximately 10% of all non-Hodgkin's lymphomas. The aim of this retrospective study was to analyse the presentation, management, outcome and significant prognostic factors in a large series of patients with PTCL. It includes 104 consecutive patients who presented to the Sheffield Lymphoma Group between 1977 and 2001. Clinical parameters were recorded for each subgroup. End points were response to treatment and survival. Survival analysis was used to assess the prognostic value of the variables. PTCL not otherwise specified contributed 52% of cases followed by anaplastic large cell lymphoma with 17% and angiocentric type with 13% of cases. The overall complete remission (CR) of the series was 59%. Stage at diagnosis affected response to treatment with 81% of cases in stage 1 and 2 achieving CR compared to 43% in stages 3 and 4 (p</=0.001). Extranodal presentations also showed a favourable response with 74% obtaining CR compared to 46% of nodal presentations (p<0.01). Median survival of all patients was 87 months with a five-year probability of survival of 52%. Variables found to be related to poor outcome are age >60 years (p<0.05), high grade histology (p<0.001), presence of B symptoms (p<0.005), nodal presentation (p<0.005) and advanced stage at diagnosis (p<0.001). Histological sub-type did not significantly correlate to outcome. In conclusion whilst a number of prognostic indicators can assist in determining the outcome in PTCL, these lymphomas are complex and often follow an unpredictable course. In order to make the best clinical decisions in individual cases, more clinical study is required.

Soft tissue, pelvic, and urinary bladder leiomyosarcoma as second neoplasm following hereditary retinoblastoma

This report describes two patients who developed leiomyosarcomas, one involving the subcutaneous tissue of the thigh and the pelvic soft tissues and the other the urinary bladder, following hereditary retinoblastoma 36 and 38 years earlier, respectively. There is an increased risk of the development of sarcoma, most commonly osteosarcoma, as a second malignancy following hereditary retinoblastoma. Leiomyosarcoma developing as a second malignancy has rarely been reported and most have occurred in the field of previous radiotherapy. The literature on leiomyosarcoma occurring as a second neoplasm following retinoblastoma is reviewed.

Localised extranodal non-Hodgkin's lymphoma of the gastrointestinal tract: Sheffield Lymphoma Group experience (1989-1998)

Extranodal non-Hodgkin's lymphoma (NHL) of the gastrointestinal tract accounts for about one third of all extranodal NHL. We retrospectively reviewed the clinical and histopathologic records of 71 patients with stage IE and IIE primary gastrointestinal NHL referred to the Sheffield Lymphoma Group (SLG) from 1989 to 1998. Cross-referencing with the Hospital Histopathology Department database revealed that only two-thirds of all cases were seen by the Group. The most common primary site was the stomach (45 patients, 63% of all cases), followed by the small intestine (16, 23%) and large intestine (9, 13%). The median age of patients was 62 years; the majority of patients presented with stage I (61%) and/or grade (65%) NHL. Mucosa-associated lymphoid tissue (MALT) lymphomas were the largest histologic subtype seen (57%), with 87% of these arising from the stomach; next most frequent was the diffuse large B-cell subtype (21% of all cases) most frequently arising from the intestine (60%). For treatment of gastric MALT lymphoma, a combined approach (surgery followed by chemotherapy, antihelicobacter therapy followed by chemotherapy) was favoured (22 cases). Five-year and 10-year overall survivals were 52% and 45% respectively. Knowledge of the Revised European American Lymphoma classification and the Helicobacter pylori/MALT association has influenced treatment approaches over the 10-year study period. For small intestinal lymphoma, surgery (with or without chemotherapy) gave 5- and 10-year survivals of 60%. Overall survival of patients with primary gastrointestinal lymphoma managed by the SLG is similar to that reported from other large series.

Copy number gain at 12q12-14 may be important in the transformation from follicular lymphoma to diffuse large B cell lymphoma

The purpose of this study was to identify novel areas of genomic copy number change associated with transformation from follicular lymphoma (FL) to diffuse large B cell lymphoma (DLBL). DNA was extracted from tumour cells micro-dissected from paraffin- embedded tissue sections in 24 patients with FL and subsequent transformation to DLBL and 18 patients with de novo DLBL. Tumour DNA was compared to reference DNA using comparative genomic hybridization. Abnormalities common to all 3 groups were gains on chromosomes 4q, 5q, 7q, 11q and X and losses on 3p, 8p and 10q. Copy number changes seen in both transformed and de novo DLBL and not seen in FL were gains on 2p and losses on 1q, 15q and Xq. Gains on 2q, 6p, 7p and 17q and losses on 5p and 8q were specific to transformed DLBL cases. Gain on 12q12-14 was found in 52% of the transformed DLBL cases and was never seen in its follicular counterpart. Patterns of genomic copy number change associated with specific clinical events in NHL have been demonstrated and suggest that gains on 2q, 6p, 7p, 12q and 17q and losses on 5p and 8q may be important in the transformation from low to high-grade disease.

Trafficking of 'immune' CD4(+)/CD8(+)T-lymphocytes into the RENCA tumour microcirculation in vivo in mice

RENCA-IL-2 (Murine Renal Cell Carcinoma transfected with murine IL-2 gene) cells were rejected by immunocompetent (but not T-cell deficient) Balb/c mice, which developed 'immunity' to subsequent parental RENCA tumour cell challenge. Splenocytes adoptively transferred this immunity. CD4(+)and CD8(+)T-lymphocytes prepared from the spleens of 'tumour immune' mice were evaluated for their ability to traffic into the tumour environment using an in vivo model that enables visualization of events within the microvasculature. RENCA cells were implanted into the mouse cremaster muscle and the trafficking of syngeneic lymphocyte subpopulations, derived from naive and 'immune' animals, into both the RENCA tumour and the surrounding normal cremaster muscle microcirculation was measured by in vivo microscopy. Fluorescently labelled CD4(+)and CD8(+)T lymphocytes taken from the spleens of naive mice or mice previously immunized with RENCA-IL-2 were injected systemically into tumour-bearer mice. Naive effector cells migrated to, and flowed through both the tumour and the normal microcirculation, with negligible adhesion. However we observed the selective recruitment, localization and arrest of immune CD4(+)and CD8(+)T lymphocytes (P< 0.05) into the tumour microcirculation, and in some instances the subsequent extravasation of cells into the tumour interstitium. Lymphocyte rolling by 'immune' CD4(+)and CD8(+)T-cells in the tumour microcirculation was greatly reduced, suggesting impaired adhesion molecule expression on the tumour endothelium. This study clearly demonstrates, by direct in vivo microscopy assessment, the localization of effector cells, CD4(+)and CD8(+)lymphocytes into tumours.

Demand management in urine cytology: a single cytospin slide is sufficient

AIMS

Current practice in most laboratories stipulates the preparation of duplicate slides for the analysis of urine cytology specimens. This study evaluates whether the duplicate slide is necessary.

METHODS

Cytospin diagnosis was assessed in three ways. First, all urine cytology preparations from a single month in 1998 were reviewed; the two slides for each case were reported separately and then the two reports on each case were examined for disparity. Second, the slides from all urine cytospin cases indexed as "suspicious" or "malignant" in 1998 were reviewed similarly. Third, 48 cytospin slides from 24 cases were divided into two randomised groups, which were reported and the two reports compared. Finally, the frequency of repeat specimen collection in cases that were deemed inadequate for diagnosis was also assessed.

RESULTS

The cases from a single month (n = 129) were representative of the annual workload and showed no discrepancies of the type: suspicious or malignant/other. Of the 60 suspicious or malignant cases from 1998, there was no disparity in 50. The 10 cases with disparity were all suspicious on one slide and degenerate on the other. In the 24 randomised cases, there was no disparity in 21. The remainder were reported as suspicious or malignant/inadequate (that is, degenerate or acellular). After a report of inadequate for diagnosis, repeat samples were received in only 15% of cases.

CONCLUSIONS

Using a single cytospin preparation causes minimal loss of clinically relevant information, but saves substantial resources (approximately 40%/case). A diagnosis of inadequate should prompt the collection of a repeat sample if the service is being used sensibly.

Placental site trophoblastic tumour: a rare but potentially curable cancer

Placental site trophoblastic tumour (PSTT) is a rare form of gestational trophoblastic disease (GTD). We have conducted an analysis of all cases of PSTT managed at the Trophoblastic Disease Screening and Treatment Centre, Sheffield, from 1984 to 1996. During this time we received 4,988 registrations for GTD and managed seven cases of PSTT. A large range of interval between antecedent pregnancy and presentation was observed - the most common presenting symptoms being irregular vaginal bleeding with or without preceding amenorrhoea. Three out of seven patients had disease confined to the uterus at diagnosis and were successfully treated by hysterectomy alone. Two out of seven patients had pulmonary metastases in addition to uterine tumour and were treated with combination chemotherapy--both are alive and well. Of the remaining two patients one had distant and the other loco-regional metastases and both died despite numerous therapeutic interventions.

Cytogenetic analysis of non Hodgkin's lymphomas by ratio-painting and comparative genomic hybridization reveals unsuspected chromosomal abnormalities

Cytogenetic analysis of cancer cells has proven to be a powerful tool in understanding malignant evolution and in providing clinically useful markers. In recent years the advent of new fluorescence in-situ hybridization (FISH) methods such as ratio-painting and comparative genomic hybridization (CGH) have enabled much more accurate karyotypes of malignant cells to be detected. In this study, we have examined the chromosomes present in malignant cells from a series of 6 low grade follicular centre and 2 high grade diffuse large cell non-Hodgkin's lymphomas (NHL) using conventional G-banding. In all cases chromosome abnormalities were observed, including the presence of marker chromosomes in six cases. The NHL cells were then subjected to the FISH method of ratio-painting. This provided a more accurate understanding of the origins of derivative chromosomes and identified the origins of all of the marker chromosomes. It also revealed hitherto unsuspected abnormalities. For example, in one case four abnormal chromosomes were demonstrated to contain material from chromosome 8, which had not been previously suspected from G-banding. Regions of amplification and deletion on the chromosomes were also investigated by CGH, which identified further unsuspected chromosomal abnormalities. For example, in case L124, trisomy of chromosome 7 was confirmed by CGH, but an unsuspected amplification of 3(p12) was also revealed. These approaches demonstrate the power of FISH technology in providing a more precise analysis of malignant cell chromosomes, and in doing so have produced comprehensive karyotypes of the NHL under study.

Semi-quantitative fluorescence in situ hybridization analysis indicates that the myc protein is consistently stabilized both before and after transformation of low-grade follicular center to high-grade diffuse large cell lymphoma

We have investigated the expression of the MYC gene at both the mRNA and protein levels to determine how these parameters are related in lymphoma cells and in nonmalignant lymphoid cells. To do this we have adopted a multicolor fluorescence in situ hybridization methodology, which has allowed us to investigate the expression of different genes at the same time in the same cell. We have made use of the digital imaging capabilities of a charge-coupled device camera system to quantify the hybridization signals for the MYC gene and, by comparing these to the expression of a control gene (glyceraldehyde-3-phosphate dehydrogenase; GAPDH), have obtained relative quantitations of MYC mRNA and protein levels. In this study we have compared cells both within and outside the germinal centers in control tissues (reactive lymph nodes and tonsils) and in low-grade follicular center lymphomas, as well as cells in high-grade diffuse large cell lymphomas. The MYC/GAPDH mRNA hybridization signal ratios were calculated and found to be higher in cell populations containing a majority of malignant cells (p < 0.04). However, when the myc/GAPDH protein hybridization signal ratios were calculated, these were significantly higher in malignant cells from all lymphomas than the ratios observed in the nonmalignant cells (p < 0.0005). These observations indicate that the environment in a malignant cell may contribute to the stabilization of the myc protein, thus enabling it to function for a longer time period than in nonmalignant cells.

Identification of different gene expression patterns in low and high grade non-Hodgkin's lymphomas by differential display

We have compared the patterns of gene expression in non-Hodgkin's lymphoma (NHL) biopsy samples from patients with either low grade or high grade disease, by the polymerase chain reaction (PCR) based technique of differential display. By using a combination of 30 primer pairs we estimate that we were able to survey over 3,000 genes expressed in these tissues. In this study we compared a group of three low grade follicular centre lymphomas with a group of two high grade diffuse large cell lymphomas and scored only those PCR products that were represented in all samples of each group. In doing so we were able to avoid many of the problems associated with the occurence of false PCR-positives. 139 differences were then scored as representing genes which may be differentially expressed during the transformation from low to high grade disease. However, as many of these might simply reflect changing populations of cells, we focused on only those genes which appeared to be expressed exclusively in either low grade or high grade disease. We have identified 14 such genes, of which 10 were low grade specific and 4 were high grade specific. This approach therefore appears to offer a systematic method for the identification and characterisation of differentially expressed genes, which are characteristic of different NHL sub-types.

Obstructive uropathy associated with myelomonocytic infiltration of the prostate

A 72 year old man was diagnosed with chronic myelomonocytic leukaemia (CMML) according to the FAB group classification. He presented with symptoms of anaemia, urinary frequency, hesitancy, and nocturia. He was later admitted with acute urinary retention and acute renal failure, which resolved with treatment. A transurethral resection of the prostate was performed. Histological examination showed fibromuscular hyperplasia with dense infiltration by myelomonocytes which stained positively with chloroacetate esterase; immunohistochemical staining was positive for lysozyme, CD43, CD45, and CD68. Following treatment with oral etoposide he transformed to acute myeloid leukaemia and eventually died. Myelomonocytic infiltration of the prostate has not been reported before. This case extends the spectrum of disease previously recognised in CMML.

Investigation of the RB-1 tumour suppressor gene in a United Kingdom series of non-Hodgkin's lymphomas

We have investigated the RB-1 tumour suppressor genes in a series of 20 non-Hodgkin's lymphomas (NHL). Polymerase chain reaction (PCR) amplification of polymorphic alleles indicated that there was evidence of allelic imbalance around 13q14, the site of the RB-1 gene, in at least 5 NHL. Immunohistochemical analysis of the RB-1 protein demonstrated wide variations in the percentage of cells exhibiting positive staining, but these usually correlated with differences in the proliferation index as indicated by staining of Ki67. Only 3/35 NHL exhibited significantly fewer cells expressing RB-1 protein than expressed Ki167. A comprehensive analysis of the mutation status of RB-1 in 20 NHL was carried out using PCR based strategies involving single strand conformational polymorphism (SSCP) gels. Most of the protein coding region was studied by analysing cDNA derived from its mRNA and the remaining 5'-end of the coding region investigated by analysing exon I of the gene. We also examined the promoter region of the gene. In none of the 20 NHL investigated were we able to identify a mutation: the only abnormal migrating fragment observed proved to be a polymorphism in exon I of the gene in 5 NHL. In one other case we detected instability at an intron repeat sequence, which had occurred during progression of the disease, but again no mutation of the protein coding region was found. The low levels of RB-1 protein expression that we had observed in a few of our NHL therefore did not appear to be due to mutation of the gene. These data suggest that mutation of RB-1 is not a common event in the evolution of NHL, but that there may be another, as yet unidentified, tumour suppressor gene near the RB-1 locus which is associated with NHL.

Investigation of the effect of BB-94 (batimastat) on the colonization potential of human lymphoma cells in SCID mice

We have assessed the effectiveness of the metalloproteinase inhibitor BB-94 (batimastat) in reducing the colonization potential of the human Burkitt lymphoma Namalwa cell line. In this study Namalwa cells were injected intraperitoneally into SCID mice and their spread to the spleen, liver and lung studied over a 3 week period. The human cells were detected in the mouse tissues by polymerase chain reaction (PCR) amplification of a human alu repeat sequence. Comparison of BB-94-treated animals with an untreated control group provided no evidence for a significant reduction in the colonization of mouse tissues by the human lymphoma cells in the presence of the drug. Tumour growth, after subcutaneous injection of the Namalwa cells into SCID mice, was similarly unaffected by BB-94. The significance of these results is discussed.

Analysis of the colonization of unirradiated and irradiated SCID mice by human lymphoma and non-malignant lymphoid cells

We have evaluated the severe combined immunodeficient (SCID) mouse as an in-vivo model for the study of non-Hodgkin's lymphomas (NHL). Characterization of the immune system of the animals in our SCID mouse colony was carried out to assess the numbers of lymphoid cells present, to determine natural killer (NK) cell activity as a function of age and to examine the histology of the lymphoid organs. In this study four human NHL established cell lines (Daudi, Namalwa, U937, MC116), lymphoma cells from four fresh NHL biopsies and normal peripheral blood mononuclear cells (PBMC) and bone marrow cells were investigated, after intraperitoneal injection into the mice. The presence of the human NHL cells in the peritoneum and spleen was assessed by FACS analysis. The colonization potential was investigated in a range of tissues by polymerase chain reaction (PCR) amplification of human repetitive sequences. These studies revealed clear differences in the abilities of the NHL cell types to colonize the SCID mice. Namalwa, Daudi and U937 cells demonstrated the highest efficiency of colonization and readily formed tumours, whereas MC116, the NHL biopsy cell populations and the non-malignant lymphoid cells showed little ability to survive and colonize other tissues in the SCID mice. Whole body irradiation of the SCID mice appeared to improve the survival of human PBMC, NHL biopsy cells and MC116 cells in the peritoneum, but had little effect on their colonization potential. The significance of these studies is discussed.

Gestational choriocarcinoma of the ovary diagnosed by analysis of tumour DNA

Gestational choriocarcinoma of the ovary is a rare form of malignancy which can be difficult to distinguish from primary ovarian choriocarcinoma. The ability to make such a diagnosis could, however, have important implications for therapy. We report here a case of choriocarcinoma whose origins were difficult to determine and which behaved clinically more like a primary rather than a gestational choriocarcinoma. We have analysed DNA from this tumour by using polymerase chain reaction (PCR) amplification of a range of polymorphic alleles and have demonstrated that the tumour was in fact gestational. Furthermore, the lack of chromosome Y sequences and the presence of heterozygosity of the spouse's alleles, indicated that this tumour arose as a result of dispermic fertilisation of an empty ovum by sperm carrying the X chromosome.

MDR-1 expression in non-Hodgkin's lymphomas is unrelated to treatment intensity or response to therapy

Over-expression of the MDR-1 gene, which codes for P-glycoprotein, is thought to be an important mechanism in the drug resistance exhibited by many tumours. A number of chemotherapeutic agents which induce MDR-1 expression are also components of combination chemotherapies that are used in the treatment of high grade non-Hodgkin's lymphomas (NHL). We have therefore examined expression of MDR-1 in a series of NHL by Northern blot analysis as well as investigated the localization of P-glycoprotein by immunohistochemistry. The series included 11 hyperplastic reactive nodes and tonsils, 17 low grade NHL and 15 high grade NHL. The levels of MDR-1 mRNA were quantified by scanning densitometry and comparison with levels of glucose-6-phosphate dehydrogenase (G6PD). The MDR-1 mRNA was observed in both non-malignant and NHL tissues. Immunohistochemical staining revealed that expression of MDR-1 mRNA in reactive nodes was related to the presence of P-glycoprotein in lymphocytes, however, P-glycoprotein was apparent in both the reactive lymphocytes and tumour cells in the NHL samples. Elevated mRNA levels (2-3 fold increase) were observed in some low grade and high grade NHL relative to those observed in reactive lymphoid tissue. There appeared to be little correlation, however, between expression of the MDR-1 gene and either treatment intensity or response to therapy. The drug resistance that is often encountered in NHL patients is therefore likely to involve mechanisms other than over-expression of P-glycoprotein.

Elevated levels of MDM-2 and p53 expression are associated with high grade non-Hodgkin's lymphomas

The role of p53 in the evolution of non-Hodgkin's lymphomas (NHL) is unclear. Mutations of the p53 gene appear to be relatively uncommon but stabilized p53 protein, as detected by immunohistochemistry, has indicated a more frequent involvement of p53. As dysfunction of p53 protein has also been suggested to occur after overexpression of the mdm-2 protein, we have therefore investigated a series of non-malignant hyperplastic reactive lymphoid tissues and NHL to examine whether the levels of expression of MDM-2 correlated to positivity of p53 protein staining. Northern blot analysis of MDM-2 expression was compared to glucose-6-phosphate dehydrogenase (G6PD) expression by densitometry to quantify the relative levels of MDM-2 expression. Consistent low levels of MDM-2 expression were observed in non-malignant lymphoid tissue and in low grade NHL, however, 13/15 high grade NHL exhibited a 2-15-fold increase in MDM-2 expression. Interestingly similar elevations in p53 mRNA expression were also observed in 6/15 high grade NHL. Positive staining of the p53 protein did not, however, correlate with elevated mRNA levels of either MDM-2 or p53. The significance of these observations is discussed.

Isolated xanthogranuloma of the limbus in an adult

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2D-gel analysis of protein synthesis profiles of different stages of chronic lymphocytic leukaemia

Protein synthesis profiles of leukaemic cells from 15 chronic lymphocytic leukaemia (CLL) patients were analysed by 2D-electrophoresis of 35S-methionine labelled proteins. This series of CLL included patients with stage A (7), B (4) and C (4) disease. Although the protein synthesis profiles were similar in all cases, some consistent differences were noted between the different stages. The levels of synthesis of three proteins (approximately 35 kD size) were of particular interest. Two of these were always expressed in stage C CLL but either infrequently or not at all in stage A or B CLL. By contrast a third protein was expressed at a much reduced level in stage C compared to stages A or B. This type of analysis could prove invaluable for identifying proteins whose expression was intimately associated with the evolution of CLL.

Comparison of protein synthesis profiles in chronic lymphocytic leukaemia cells and B-lymphocytes from peripheral blood, cord blood and tonsil

2D-gel electrophoresis was used to investigate protein synthesis in leukaemic cells from a series of 15 chronic lymphocytic leukaemia (CLL) patients, and in non-malignant B-cell populations from different sources. The protein synthesis profiles of CD5+ B-cells from umbilical cord blood and from tonsil were determined, and the levels of expression of their proteins were observed to be similar to the CLL cells. The CD5- cells from cord blood resembled peripheral blood B-lymphocytes, and the protein synthesis profile of CD5- cells from tonsils was very complex. One protein was also identified which consistently appeared to be synthesised at a low level in CD5+ B-cells from tonsil but which was always more prominent in CLL cells and other non-malignant B-lymphocytes. On the basis of these data it is possible that the closest non-malignant counterpart to CLL is the CD5+ B-lymphocyte from cord blood.

Analysis of the p53 gene, its expression and protein stabilization in non-Hodgkin's lymphomas

We have investigated the p53 gene, expression of its mRNA, and stabilization of its protein in a series of non-Hodgkin's lymphomas (NHLs). Immunohistochemistry revealed positive staining of the p53 protein in node biopsies from 6/36 NHL patients, all of whom had high-grade disease. The remaining NHL samples, together with 3 reactive nodes, showed either negative staining or the staining of only occasional cells. In one case that exhibited intense nuclear staining in 90% of the cells, a mutation in the p53 gene was also observed. There was no evidence of rearrangements of the p53 gene in any of the NHL samples. Although p53 mRNA could not be detected in nonmalignant tissue, it was apparently overexpressed in 16/38 NHL, but this did not correlate with positive staining of the p53 protein. These data suggest that p53 dysfunction might play an important role in the evolution of some cases of NHL, and that mechanisms other than mutation of the p53 gene may be involved in stabilizing the p53 protein in these neoplasms.

Investigation of the activation state of the X chromosome in non-Hodgkin's lymphomas

Cytogenetic analysis of non-Hodgkin's lymphomas (NHLs) has previously revealed a high incidence of numerical abnormalities involving the X chromosome. We have now used a combination of fluorescence in situ hybridization (FISH) and Southern blot analysis of methylation to examine the activation state of additional X chromosomes in NHL. Although FISH analysis of X chromosome centromeres in interphase nuclei was complicated by a number of factors, such as cell-cycle position, there was evidence that more than one X chromosome was present in the active state in 4/9 NHL. Methylation studies were carried out using the M27 beta probe, which also suggested that more than one activated X chromosome was present in at least 2/7 NHL cases. The two approaches therefore provided evidence that in some cases of NHL, unlike sex-chromosome-syndrome individuals, additional X chromosomes may be present in the active state. These data support the suggestion that NHL-associated oncogenes might be located on the X chromosome.

Investigation of BCL-2 gene rearrangements in a United Kingdom series of low and high grade non-Hodgkin's lymphomas

Rearrangements of the BCL-2 gene are thought to be the most frequent genetic changes that occur in non-Hodgkin's lymphomas (NHL), and are particularly associated with follicular low grade disease. Wide variations in the frequency of these rearrangements have, however, been reported in studies of NHL series from different parts of the world. We were therefore interested to determine the frequency of BCL-2 gene rearrangements in the different grades of NHL from a U.K. series. We have done this by using a combination of Southern blot hybridization and polymerase chain reaction (PCR) analysis. The frequencies of rearrangements in our series were 9/20 (45%) in low grade follicular NHL, 1/8 (12.5%) in low grade lymphocytic and 5/19 (26%) in high grade NHL. However, estimation of the high grade value was complicated by the fact that a number of the high grade samples in our series were from patients who had transformed from low grade follicular disease. If the patients were ranked on the basis of whether they had a history of low grade follicular disease then the frequency of BCL-2 rearrangement remained the same 13/29 (45%), but was only 1/10 (10%) in high grade NHL with no history of follicular disease. The former figure was intermediate between those reported for the USA and Japan series, but the latter high grade figure was the lowest reported from any series. The significance of BCL-2 rearrangements in the evolution of both low and high grade NHL is discussed.

Investigation of the expression of housekeeping genes in non-Hodgkin's lymphoma

Studies of quantitative changes in gene expression in malignant cells have often used housekeeping genes as controls against which the level of expression of a gene under study could be compared. We have now examined whether the expression of the most commonly used of these housekeeping genes can be regarded as reliable controls for gene expression studies in non-Hodgkin's lymphoma (NHL). We have used Northern blot analysis to compare the levels of expression of beta-actin, alpha-tubulin, beta 2-microglobulin and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) to that of ribosomal RNA. These studies demonstrated that whereas there was a reasonable correlation between the relative levels of rRNA and housekeeping gene expression in reactive hyperplastic nodes, there were major differences in the relative levels of expression of the housekeeping genes in both low and high grade lymphomas; only GAPDH showed any degree of consistency. These observations indicated that housekeeping gene expression was not a reliable control for estimating changes in the level of expression of other genes in NHL, and instead suggested that 18S or 28S rRNA expression offered a more accurate method of RNA quantitation.

2D-gel analysis of proteins in chronic lymphocytic leukemia cells and normal B-lymphocytes

Protein synthesis was analysed in leukaemic cells from 10 chronic lymphocytic leukaemia (CLL) patients by 2D-gel electrophoresis of 14C-labelled proteins. There appeared to be only minor differences between each of the CLL samples, but there was evidence that the level of expression of a few of the proteins might have correlated to the stage of the disease. Comparison of the CLL samples to populations of normal B-lymphocytes demonstrated marked differences in protein synthesis between the leukaemic and non-malignant cells. We subsequently used the fluorescence activated cell sorter (FACs) to separate CD5+ from CD5- B-lymphocytes, but observed that the protein synthesis exhibited by these two populations was essentially the same, and both were very different to that observed in CLL cells. The significance of these observations with respect to the origins of CLL is discussed.

Cytogenetic analysis of a United Kingdom series of non-Hodgkins lymphomas

We describe cytogenetic analyses of cells derived from 40 non-Hodgkins lymphoma (NHL) node biopsies, 23 of which were from patients who had not been treated before biopsy. We noted that the chromosomes most frequently gained were X (32%), 12 (27%), and 3 (24%). Monosomies were much less common; loss of chromosome 13 (13.5%) was most frequent. Structural abnormalities primarily involved chromosomes 14 (70%), 1 (40.5%), 18 (38%), 6 (35%), and 17 (22%). Low-and high-grade disease showed similar patterns of structural changes; however, a markedly greater number of chromosome gains were associated with low-grade disease. Biopsy samples from patients who had previously been treated showed an increased frequency of structural abnormalities, as well as a significantly larger number of chromosome gains. The importance of these observations, particularly with regard to possible oncogene involvement in lymphoma evolution, is discussed.

Loss of monomorphic and polymorphic HLA antigens in metastatic breast and colon carcinoma

MHC class I antigens are intimately involved in intercellular communication, and recognition by cytotoxic T cells. Thus tumour cells that fail to express them may be at a growth or metastatic advantage. A series of ten colorectal and ten breast carcinomas, and their respective lymph node metastases, were examined immunohistologically using monoclonal antibodies (mAb) against both monomorphic and A2 polymorphic determinants, and beta-2-microglobulin (beta 2m). Four colon polypoid adenomas stained positively throughout, but 6/10 primary tumours had partial or complete loss of expression of monomorphic determinants using mAb W6/32: two node and the liver metastasis showed less, four more expression. Similar results were seen for beta 2m. HLA-A2 expression was absent or reduced in 4/4 colon tumours and all their metastases. Among the breast tumours, W6/32 staining was absent or reduced in 2/10, and node deposits showed two with less reactivity than their primary. Beta 2m staining was reduced or absent in 8/10 primaries and all the node metastases; in every case in which beta 2m was detected in the primary tumour their corresponding lymph node metastasis showed a decreased expression. HLA-A2 expression was absent or reduced in 3/4 primary breast carcinomas, and all their metastases. These results show that individual human colon and breast carcinomas often have a reduced HLA class I antigen expression, which apparently confers a metastatic advantage.

Natural killer cell activity following cryosurgery of normal and tumour bearing liver in an animal model

Cryosurgery is a useful tool to treat unresectable liver carcinoma. In addition to the local effects of freezing, cryosurgery is thought to affect host immune response. We tested this by measuring natural killer (NK) cell cytotoxicity following cryosurgery of normal liver and an implanted liver tumour in the rat. Controls underwent sham cryosurgery. NK cytotoxicity was enhanced following cryosurgery of normal liver and liver tumour.

Somatic allelic deletion of nm23 in human cancer

Tumor progression to the metastatic phenotype is accompanied in certain cell types by reduced expression of the nm23 gene. We have localized human nm23-H1 to chromosome 17 by somatic cell hybrid analysis. Regional localization in the CEPH database and in situ hybridization is reported. Somatic allelic deletion of nm23-H1 was observed in human breast, renal, colorectal, and lung carcinoma DNA samples, as compared to DNA from matched normal tissues. A homozygous deletion of nm23-H1 was observed in a lymph node metastasis of a colorectal carcinoma, indicating that nm23-H1 can be recessively inactivated. The data identify nm23-H1 as a novel, independent locus for allelic deletion in human cancer, a characteristic shared with previously described suppressor genes.

Intra-abdominal neuroectodermal tumour of childhood with divergent differentiation

Two cases are reported of intra-abdominal small cell tumours expressing concomitant neural and epithelial differentiation. These features were discernible on conventional microscopy and supported immunocytochemically. Immunoreactive vimentin was also revealed in both tumours, and, in addition, one showed focal desmin positivity. Epithelial differentiation in both tumours was confirmed ultrastructurally. The tumours were interpreted to represent a variant of peripheral primitive neuroectodermal tumour, and the report serves to emphasize a potential among such tumours for complex differentiation. The neoplasms are compared with other similar tumours reported recently in children.

Secondary tumour deposits in needle biopsy tracks: an underestimated risk?

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Basosquamous carcinoma, a wolf in sheep's clothing? Report of 3 cases

Basosquamous carcinoma of the skin is a lesion with specific histological features and recognized metastatic potential. Three cases of metastatic basosquamous carcinoma are reported, two of which were rapidly fatal. They illustrate that diagnostic features may be absent in a small biopsy and that metastasis is usually associated with a poor prognosis.

Metastatic teratoma associated with an intra-abdominal abscess

A case of metastatic testicular teratoma is reported where histological evidence of metastatic disease was obtained 12 years after orchidectomy. The patient had presented again 2 years earlier but the presence of a large intra-abdominal abscess delayed the diagnosis of recurrence. At no time were the serum levels of alpha-fetoprotein or beta human chorionic gonadotrophin elevated.

Immunohistological demonstration of progesterone receptor in breast carcinomas: correlation with radioligand binding assays and oestrogen receptor immunohistology

The validity of determining the progesterone receptor status of breast carcinomas with a monoclonal antibody was investigated by comparison with data from a radioligand binding assay on adjacent cryostat sections of 103 tumours. Significant nuclear staining for progesterone receptor was observed in 37 (36%) of the tumours studied and this showed a close correlation with the results of radioligand binding assays for progesterone receptor. In three progesterone receptor positive tumours there was an apparent paradoxical absence of oestrogen receptor; progesterone receptor normally depends on the presence of oestrogen receptor, but these rare tumours may be essentially progesterone receptor positive. It is concluded that this monoclonal antibody is an appropriate reagent for use in the immunohistological determination of progesterone receptor status of breast carcinomas; that it advantageously identifies both the occupied and unoccupied receptor sites; and that it provides information about tumour cell heterogeneity with respect to receptor status.

Comparison of excision versus cryosurgery of an HSV-2-induced fibrosarcoma. I. Survival, extent of metastatic disease and host immunocompetence following surgery

Cryosurgery and excision were used to treat primary tumours of HSV-2-transformed hamster tumour sublines, and post-operative survival and the extent of metastatic disease were compared in the two groups. An inferior prognosis was observed following cryosurgery although the extent of metastatic disease was similar in both groups. Using this model it would appear that cryosurgery enhances the development of micrometastases rather than affecting the number of cells shed from the primary tumour during surgery. To investigate the underlying causes of the decrease in survival following cryosurgery, in vitro assays were used to monitor host immunocompetence following surgery. The results showed that whilst natural killer cell cytotoxicity was only marginally depressed, mitogen responsiveness and lymphocyte participation in a mixed lymphocyte reaction were severely reduced 3-7 days post-cryosurgery. In parallel with immunosuppression, extensive cell proliferation in the spleen of cryosurgically treated tumour-bearing animals was observed. Histological examination of the spleen demonstrated the presence of large numbers of transformed cells which correlated with the loss of mitogen responsiveness and the ability to participate in a mixed lymphocyte reaction. Further studies (manuscript submitted for publication) have demonstrated that spleen cells from animals whose tumour is treated by cryosurgery are capable of suppressing immunocompetence in vitro, implying they have a role in the uncontrolled growth of micrometastases in vivo.

The effect of the immune status of the TAR mouse on the growth and metastasis of tumour xenografts

Mice thymectomised at 3-4 weeks of age and subsequently given whole-body irradiation (9 Gy) under cytosine arabinoside cover (TAR mice) provide an alternative model to the athymic nude (nu+/nu+) mouse for studying the biological characteristics of tumour xenografts. In the present study we have evaluated the repopulation events in the bone marrow and spleen following whole body irradiation of TAR mice, and analysed immune competence up to 98 days following irradiation. Repopulation of both bone marrow and spleen was evident in the weeks following whole body irradiation, and an initial increase in the relative proportion of T-lymphocytes present in the spleen was followed by a decrease in the percentage of lymphocytes expressing T-cell markers, which remained below the level observed in control mouse spleen cell preparations. TAR mice exhibited a decreased ability to respond to a non-specific T-cell mitogen and to elicit a T-cell dependent antibody response to influenza viral antigen. Both TAR and control mice possessed macrophages which could be activated to the tumouricidal state, and natural killer activity of TAR mice was enhanced greater than 3-fold above control values. The ability of TAR mice to accept tumour xenografts decreased with the increasing time interval between irradiation and subcutaneous implantation of tumour cells, and (in some instances) spontaneous regression was observed. In addition, a hamster tumour cell line possessing high metastatic potential in its syngeneic host was shown to metastasise to the regional lymph node, lungs, liver, kidneys and spleen of TAR mice from a cell inoculum implanted subcutaneously immediately after irradiation; however, with increasing time between irradiation and inoculation of tumour cells tumour metastasis decreased. The ability of TAR mice to support the growth and metastasis of tumour xenografts would appear to inversely correlate with the increase in natural killer cell activity following irradiation.

Bilateral pneumothorax secondary to metastatic angiosarcoma of the breast

Bilateral spontaneous pneumothorax is a rare complication of pulmonary metastases. We report a 44 year old woman who developed this complication a few months after undergoing mastectomy and postoperative radiotherapy for primary angiosarcoma of the breast.

Giant vascular eccrine spiradenomas: a report of two cases with histology, immunohistology and electron microscopy

Two examples of a variant of benign spiradenoma are reported, both characterized by their large size and high degree of vascularity. The results of studies using light microscopy, transmission electron microscopy and immunohistology are described. The relationship of this unusual variant to other spiradenomas and their eccrine sweat gland origin is discussed. The possible misdiagnosis of this rare type of spiradenoma is emphasized.

Haematuria due to urinary bladder metastases from small cell carcinoma of the bronchus

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