Clinical and histopathological study of angiogenesis in multiple myeloma.

PURPOSE: Angiogenesis is an essential component in the growth and progression of multiple myeloma (MM). We studied the clinical significance of angiogenesis in patients with MM estimated by precise counting of the number of vessels (i.e. microvessel density, MVD) and compared these results with the results obtained using semi-quantitative grading of angiogenesis. METHODS: Fifty-nine newly diagnosed cases of MM were analyzed with respect to clinical features, laboratory findings, histological features, angiogenesis parameters, and response to treatment. Bone marrow microvessels were examined using immunohistochemical staining for CD34. Bone marrow angiogenesis was estimated by two different methods. The mean number of vessels per area in each sample was characterized as the MVD. Microvessels were counted manually on light microscopy in 3 hot spots at ×400 magnification. Semiquantitative estimation of angiogenesis was based on visual assessment of slides at ×100 magnification. Each slide was assigned as low, intermediate or high intensity of angiogenesis. RESULTS: The median MVD was 15 vessels per 3 hot spots (range 1-89). Intensity of angiogenesis was assigned as low in 24 (40.7%) patients, intermediate in 17 (28.8%) and high in 18 (30.5%). Significant correlation between intensity of angiogenesis (estimated using both methods) and histological grade, extent of bone marrow infiltration, proliferative activity of myeloma cells and poor survival was found. Semiquantitatively assessed intensity of angiogenesis additionally correlated with clinical stage. There was a statistically highly significant correlation between MVD and semi-quantitatively estimated intensity of angiogenesis (p <0.001). CONCLUSION: Tumor-associated angiogenesis is an important prognostic feature in MM and should be routinely done on bone marrow biopsies of these patients. Simple semiquantitative grading of angiogenesis can be recommended for daily practice, as an alternative method for complicated and time-consuming estimation of MVD.

Expression of VEGF and microvessel density in patients with multiple myeloma: clinical and prognostic significance.

The conflicting data are reported on the clinical significance of VEGF deregulation and intensity of angiogenesis in multiple myeloma. The aim of this study was to evaluate the incidence and prognostic significance of VEGF expression and microvessel density (MVD) in multiple myeloma, as well as the relationship of their expression with selected clinical data, histological features, and proliferative activity of myeloma cells. We analyzed bone marrow biopsy specimens obtained from 59 patients with newly diagnosed multiple myeloma. Expression of VEGF and MVD was analyzed using standard immunohistochemical method (antibodies against VEGF and CD34, respectively) on B5-fixed and routinely processed paraffin-embedded bone marrow specimens. MVD was estimated by counting the number of microvessels in three "hot spots" at 400x magnification. VEGF immunoreactivity was estimated on the basis of intensity and percentage of positive plasma cells. VEGF was expressed in 47/59 (79.7%) specimens. There was no significant correlation between VEGF overexpression and age, clinical stage, the extent of osteolytic lesions, type of monoclonal protein, hemoglobin concentration, platelet count, serum concentration of creatinine, calcium, and albumins, the extent of bone marrow infiltration, histological grade, and proliferative activity index (measured with Ki-67 immunoreactivity). No significant difference was observed regarding the overall survival between VEGF-positive and VEGF-negative patients (29 vs. 34 months, P = 0.8). Median MVD was 15, ranging from 1 to 89 microvessels per three "hot spots". There was significant correlation between MVD and histological grade, the extent of bone marrow infiltration, and proliferative activity. Significant difference was observed regarding the overall survival between patients with low MVD (<15) and patients with high MVD (> or = 15) (46 vs. 22 months, P = 0.009; univariate analysis). The results of this study did not reveal clinical significance of VEGF overexpression in multiple myeloma. On the contrary, the extent of bone marrow angiogenesis is an indicator of biological potency of malignant clone and a predictor of poor survival in newly diagnosed myeloma.

Extranodal marginal zone B-cell lymphoma most probably of MALT type appearing in CNS as parasagittal extracerebral tumor.

A 63 years old male patient with systemic extranodal marginal zone lymphoma, most probably originating from mucosa associated lymphoid tissue (MALT) involving central nervous system (CNS) is presented. The usual site of origin of this type of lymphoma was not identified. The diagnosis was stated after neurosurgery according to histopathology, immunohistochemistry and additional haematologic examination. Postoperative therapy included local irradiation (30Gy) of rest tumor, combined by Rituximab-CHOP (R-CHOP) protocol, which resulted in complete remission lasting three years up to now.

Successful treatment of extranodal Hodgkin's lymphoma in a patient with longstanding hairy cell leukemia.

Purine analogs, particularly pentostatin and cladribine, are highly effective in hairy cell leukemia (HCL). Both of these drugs induce responses in approximately 80-95% of patients. However, it is not yet determined if treatment with these drugs can induce second malignancies. Hodgkin's lymphoma is very rare as a second malignancy and there are only 3 reported cases concerning the association of this lymphoma with HCL. We describe a patient with longstanding HCL in complete remission after cladribine, in whom extranodal Hodgkin's lymphoma appeared 8 years after the diagnosis of HCL. Magnetic resonance imaging revealed diffuse intra-osseal neoplastic infiltration of the corpora of the whole spinal column and extra-osseal propagation from the fifth thoracic vertebra into the spinal canal with spinal cord compression. Histological and immunohistochemical analysis of the extradural tumor, which was completely excised, disclosed nodular sclerosis Hodgkin's lymphoma with typical Reed-Sternberg cells that were positive for CD30, CD15, bcl-6, Ki67, p53, EBV LPM-1 and IgG, and negative for CD45, CD20, DBA44, kappa, lambda light chains and IgM. In addition, immunohistochemical analysis of the bone marrow in 1999 showed infiltration with positivity for IgM and negative for kappa light chains and IgG. These findings (expression of different immunoglobulins and light chains on the cells) suggest an independent origin of these 2 B-cell neoplasms. After neurosurgery the patient received 6 courses of the MP-ABVD protocol and achieved a complete remission, which has lasted 16 months thus far.

Myelofibrosis in primary myelodysplastic syndromes: clinical and biological significance.

In a retrospective study of 236 patients with primary myelodysplastic syndromes (MDS), 130 cases (55.1%) revealed myelofibrosis in bone marrow biopsies. It was observed that fibrosis mostly occurs focally or patchy, and collagen deposits were found very rarely (only four patients). The histopathology of bone marrow biopsies revealed several differences between fibrotic and non-fibrotic MDS: cellularity is significantly higher, dysmegakaryopoiesis is more pronounced, plasmocytes and mast cells are more often increased, and disturbance of marrow topography (particularly of the MK- and G-line) can be found more frequently in MDS with myelofibrosis. Reticulin fibrosis occurred in all subtypes of MDS; however, there was a higher incidence in chronic myelomonocytic leukemia. The frequency of abnormal growth of GM-progenitors was significantly higher in the MDS cases with myelofibrosis, compared to the cases without fibrosis. Clinical data showed significantly higher WBC, more frequent presence of immature granulocytes, and higher percentage of myeloblasts in peripheral blood and bone marrow in MDS with myelofibrosis compared to cases without myelofibrosis. Life expectancy was reduced to 13 mo, compared with 35 mo in MDS without fibrosis (p=0.00055). Time to leukemic transformation was 32 mo in MDS with fibrosis, compared with >56 mo in MDS without fibrosis (p=0.015). Myelofibrosis therefore seems to herald a poor prognosis.

Immunohistochemical analysis of cyclin D1 and p53 in multiple myeloma: relationship to proliferative activity and prognostic significance.

Conflicting data are reported on the clinical significance of cyclin D1 deregulation in multiple myeloma. The aim of this study was to evaluate the incidence and prognostic significance of cyclin D1 expression and p53 mutations in multiple myeloma, as well as the relationship of their expression with selected clinical data, histological features, and proliferative activity of myeloma cells. We analyzed bone marrow biopsy specimens obtained from 59 patients with newly diagnosed multiple myeloma. Expression of cyclin D1 and p53 was analyzed using standard immunohistochemical method of B5-fixed and routinely processed paraffin-embedded bone marrow specimens. Cyclin D1 was overexpressed in 14/59 (27%) and p53 in 5/59 (8.5%) specimens. There was no significant correlation between cyclin D1 overexpression and age, gender, clinical stage (Durie-Salmon classification), extent of osteolytic lesions, type of monoclonal protein, hemoglobin concentration, platelet count, serum concentration of creatinine, calcium, C-reactive protein, and beta2-microglobulin. No association was observed between the expression of cyclin D1 and the extent of bone marrow infiltration, histological grade, proliferative activity index (measured with Ki-67 immunoreactivity) and response to therapy. No significant difference was observed regarding overall survival between cyclin D1 positive and cyclin D1 negative patients (29 vs 36 mo, p = 0.76). Results of this study did not revealed prognostic significance of cyclin D1 overexpression in multiple myeloma. Mutations of p53 gene are rare events in myeloma, suggesting their limited role in the pathogenesis of the disease.

Granulocytic sarcoma of the brain in a patient with acute myeloid leukemia.

Granulocytic sarcoma is extramedullary tumor composed of immature leukemic cells most frequently located in close proximity to bone, but it also can be found in the skin, breast, gastrointestinal tract, ovaries and brain. Granulocytic sarcoma may arise during the course of leukemia or precede its development in the bone marrow. The majority of reported cases of granulocytic sarcomas in acute myleoid leukemia have chromosome translocation t(8;21). We report a 46-year-old man with acute myeloid leukemia, type M2 involving the marrow and peripheral blood and chromosome t(8;21) who developed granulocytic sarcoma in the brain, as a first manifestation of relapse 6 months after complete remission was achieved. During a neurosurgical operation a cortically located tumour (3.5 x 5 cm) in the brain was partially removed. Histology showed tumor consisted of homogenous infiltrate of blasts, admixted with more mature haematopoietic cells. The blasts have large round to oval nuclei, delicate chromatin, one or more small well-defined nucleoli and scant basophilic cytoplasm. Immunohistochemistry showed that blast cells were myeloperoxidase positive, confirming the diagnosis of myeloblastic sarcoma in the brain. The patient died two days after surgery.

[Gastrointestinal stromal tumor of small intestine--case report]. / Gastrointestinalni stromalni tumor tankog creva.

Gastrointestinal stromal tumor is a form of mesenchimal neoplasm that may be present in all parts of gastrointestinal system. We are reviewing diagnostic and therapeutic algorithms for patient with diagnosed gastrointestinal neoplasm of small intestine, experiencing repeated episodes of painful bleeding from gastrointestinal trackt.

Secondary myelofibrosis in visceral leishmaniasis--case report.

A 39-year-old woman with a history of travel to the Montenegrin coast presented with a 9-month long history of fever and weakness, and on examination was found to be emaciated with hepatosplenomegaly and pancytopenia. Marrow aspiration showed poor cellularity with abundant Leishman Donovan (LD) bodies in the macrophages. Bone marrow trephine biopsy revealed a marked myelofibrosis (Manoharan classification: grade III) with osteosclerosis. The impression smears of a trephine biopsy stained with Güiemsa also showed LD bodies. The patient did not exhibit evidence of any risk factors for visceral leishmaniasis (VL). She was treated with meglumine antimoniate (Glucantime) without any adverse effect. The spleen returned to a normal volume after 4 months and bone marrow trephine biopsy performed 6 months after initiation of the therapy had returned to normal. A diagnosis was difficult to establish as VL is rarely encountered in the continental parts of Yugoslavia, and with the presence of associated myelofibrosis it could easily have been mistaken for chronic idiopathic myelofibrosis. The association of myelofibrosis with visceral leishmaniasis has been reported in the literature only three times; we thus feel that documentation of this case is merited.

T-cell-rich B-cell lymphoma: a clinicopathologic study of eight cases.

T-cell-rich B-cell lymphoma (TCRBCL) is a recently recognized and ill-defined form of non-Hodgkin's lymphoma (NHL), with no generally accepted diagnostic criteria and with limited information regarding its incidence, cellular origin, morphologic spectrum and biologic behavior. The recent findings suggest that TCRBCL could be a biologically distinct disease characterized by male preponderance, advanced-stage disease initially and high incidence of extranodal localization, especially in the bone marrow. For the time being, proper diagnosis rests on the immunohistochemical identification of the scattered large malignant B-cells amid a sea of small reactive T-lymphocytes. In this study, the clinicopathologic features of 8 patients (pts) with TCRBCL are presented. The male to female ratio was 5/3, and the median age was 52 years (32-67). The disease was advanced in most patients: 5 pts with stage IV and 2 pts with stage III. The patients presented with generalized lymphadenopathy (5), splenomegaly and/or hepatomegaly (4) and bone marrow involvement (4). The diagnosis of TCRBCL was initially established in 6 pts, while the remaining 2 pts were initially diagnosed as having Hodgkin's disease (of mixed cellularity in 1 pt and lymphocytic predominance in another). Revision of the 2 samples comprising immunohistochemistry enabled diagnosis of TCRBCL. Immunohistomorphologically the present series can be differentiated from other types of lymphoma such as lymphocyte-predominant Hodgkin's disease and peripheral T-cell lymphoma.

[Successful treatment of primary myelofibrosis with thrombocytosis during pregnancy with alfa-interferon]. / Uspesno lecenje primarne mijelofibroze s trombocitozom u trudnoci primenom alfa-interferona.

Primary myelofibrosis is predominantly a disease of old age, poor prognosis and no curable treatment. Thrombocytosis was observed in only 12% of patients. To our knowledge, there is only one reported case of a young woman with primary myelofibrosis who had a term pregnancy [1]. We report on a 29-year-old woman with thrombocytosis and medical history of two miscarriages in the last 2 years, the iirst at 30 weeks of gestation and the second at 27 weeks. Multiple placental infarctions were observed. She was without symptoms but with moderate splenomegaly 4.5 cm below left costal margin). The platelet count was 651 x 10(9)/L, WBC 7.2 x 10(9)/L with normal differential formula, and haemoglobin level 12 g/dl. Bone marrow biopsy showed fibrotic phase of primary myelofibrosis, with hyperplasia of megacaryocytes, decreased numbers of erythroid and granulocytic cells, and increased amounts of reticulin fibres. Cyctogenetic examination of the bone marrow showed normal female caryotype. Increased numbers of progenitors CFU-Mk, CFU-GM and BFU-E were observed in peripheral blood, and decreased numbers in bone marrow cultures. As the patient wished to become pregnant, the treatment with interferon-a (Roferon A) was started at a dose of 3 MU s.c., three times per week. The platelet count rapidly decreased at a level of 260-370 x 10(9)/L. The pregnancy was diagnosed 5 months later. At the 24 week of pregnancy, platelet count raised to 690 x 10(9)/l and the dose of interferon-a was augmented, 3 MU every day, until delivery. Foetal growth and placental circulation were monitored by serial ultrasonography. At the end of 34 weeks of pregnancy, it was noted that placental flow became insufficient, and after foetal lung maturity was stimulated with dexamethasone, Cesarean section was performed. Male baby was born, weighting 2000 g, with respiratory distress syndrome. This complication was successfully treated, and the child is now one year old, with normal growth and development. The mother is still on therapy with interferon-a, 3 MU, three times a week, and the last blood count was as follows: haemoglobin 10.7 g/dl, WBC 6.1 x 10(9)/L and platelet comt 437 x 10(9)/L. In conclusion, according to the clinical results of interferon-d in thrombocytosis and experimental studies which showed the absence of placental transfer of interferon-d, this therapy could be recommended to women with primary myelofibrosis who wish to have a baby.

Disseminated Burkitt's-like lymphoma during pregnancy.

The occurrence of Burkitt's-like lymphoma (BL) during pregnancy is rarely diagnosed and its outcome is poor. A case of BL localized in the uterus, ovaries and breast during the course of pregnancy is presented. The patient was treated with a combination of surgery and chemotherapy and was disease-free for 6 months after the diagnosis.

[T-cell-rich B-cell lymphoma]. / Limfom celija "be" bogat celijama "te".

The authors present three patients, one female and two males, with special forms of non-Hodgkin's lymphoma, the so called T-cell rich B-cell lymphoma (TCRBCL). This is a relatively new entity which has not yet been described in our literature. The first diagnosis in our female patient was Hodgkin's disease. However, the revision of old and new lymph node samples and use of immunohistochemical analysis helped the establishing of diagnosis--TCRBCL. In the other two patients the diagnosis of TCRBCL was established on the basis of immunohistochemical analysis of the lymph node which indicated the dominating T-lymphocytes, positive to pan-T antigen (CD45 RO+), with considerably lower count of B-lymphocyte elements positive to CD20+. The female patient survived 33 months from the time of diagnosis. The other two patients experienced complete remission lasting 10 and 12 months after the end of therapy.

[Hamartoma of the spleen]. / Hamartom slezine.

Hamartoma is a rare benign lesion of the spleen. Between 140 and 150 cases seem to have been described so far. Hamartoma of the spleen may appear as a single or multiple lesions which may tend to converge. It appears in all ages, mainly in elderly persons. About 20% of patients were described in paediatric subjects. Half of the patients have no symptoms, so that hamartomas were discovered by chance at autopsy. Other 50% of patients had pain, splenomegaly, haematologic abnormalities (most frequently thrombocytopenia or pancytopenia) and spontaneous rupture with intra-abdominal bleeding. In children, hamartoma of the spleen with haematologic abnormalities may be followed by growth retardation, frequent infections, fever and night sweating. The bigger the hamartoma the greater probability to cause symptoms. The exact preoperative diagnosis is rarely established. Hamartoma has to be taken into account always when tumour of the spleen is diagnosed, particularly in children. Splenectomy is the most frequent treatment of symptomatic hamartoma of the spleen. Partial splenic resection is the preferred surgery whenever it may be carried out, particularly in children. We report a 58 year old woman with a five-year history of left subcostal and lumbar pain in whom in the lower pole of moderately enlarged spleen a tumorous mass, 107 x 75 mm in diameter, was discovered on ultrasonography. She was submitted to splenectomy as well as to cholecystectomy due to gall bladder stones. Histological findings of the spleen showed hamartoma. She had an uneventful recovery. The pain disappeared after surgery. She stayed symptom free so far.

Primary MALT lymphoma of the kidney.

A primary mucosa associated lymphoid tissue tumor (MALT) of the kidney in a 50-year-old man who suffered from on therapy resistant high blood pressure over 15 years period is presented. A mass in the right kidney (6x5x3 cm) during routine check up was discovered on ultrasonography and confirmed on CT scan and NMR. The patient was submitted to nephrectomy. A mass involving kidney, pyelon and upper part of the ureter was found. Histology showed low grade non-Hodgkin B-cell lymphoma of MALT type. The neoplastic cells were positive for monoclonal antibodies CD20, CD79alpha, surface and cytoplasmic and IgM immunoglobulins and showed light chain restriction (kappa+). After histology was available, a careful staging was performed. The disease was not found anywhere else. It was concluded that the patient belonged to the stage IE of primary kidney MALT lymphoma. Gastroscopy showed signs of chronic superficial gastritis. Urease test was positive and IgG antibodies against Helicobacter pylori in titer 421 were found as well. Except for Helicobacter pylori no additional therapy was given.

Non-secretory solitary plasmacytoma of the spleen.

A case of primary nonsecretory plasmacytoma of the spleen is reported. On laparotomy and splenectomy a 920 g spleen was removed, measuring 16 x 14 x 6 cm. The cut surface of the entire spleen showed that the tumour occupied most of the splenic tissue. A bone marrow aspirate and trephine, skeletal survey showed no signs of myeloma. Biopsy of the liver and regional lymph nodes was normal. Immunocytochemistry of the splenic tumour showed positivity for pan-B and plasma cell markers. After splenectomy the patient was treated with chemotherapy according to protocol VBCMP (M2).