Persistent preswitch clonotypic myeloma cells correlate with decreased survival: evidence for isotype switching within the myeloma clone.

Multiple myeloma (MM) is identified by unique immunoglobulin heavy chain (IgH) variable diversity joining region gene rearrangements, termed clonotypic, and an M protein termed the "clinical" isotype. Transcripts encoding clonotypic pre and postswitch IgH isotypes were identified in MM peripheral blood mononuclear cells (PBMCs), bone marrow (BM), and mobilized blood. For 29 patients, 38 BM, 17 mobilized blood, and 334 sequential PBMC samples were analyzed at diagnosis, before and after transplantation for 2 to 107 months. The clinical clonotypic isotype was readily detectable and persisted throughout treatment. Eighty-two percent of BM and 38% of PBMC samples also expressed nonclinical clonotypic isotypes. Clonotypic immunoglobulin M (IgM) was detectable in 68% of BM and 25% of PBMC samples. Nonclinical clonotypic isotypes were detected in 41% of mobilized blood samples, but clonotypic IgM was detected in only 12%. Patients with persistent clonotypic IgM expression had adverse prognostic features at diagnosis (lower hemoglobin, higher beta(2)-microglobulin) and higher numbers of BM plasma cells compared with patients with infrequent/absent clonotypic IgM. Patients with persistent clonotypic IgM expression had significantly poorer survival than patients with infrequent IgM expression (P <.0001). In a multivariate analysis, persistent clonotypic IgM expression in the blood correlated independently with poor survival (P =.01). In nonobese diabetic severe combined immunodeficiency mice, xenografted MM cells expressed clinical and nonclinical postswitch clonotypic isotypes. MM expressing clonotypic IgM engrafted both primary and secondary mice, indicating their persistence within the murine BM. This study demonstrates that MM clonotypic cells expressing preswitch transcripts are tied to disease burden and outcomes. Because MM pathology involves postswitch plasma cells, this raises the possibility that IgH isotype switching in MM may accompany worsening disease.

Prevalence of gastrointestinal helminths in domestic bison herds in northwestern Alberta.

A fecal survey was conducted to determine the prevalence of gastrointestinal helminth eggs found in 431 domestic bison from 22 herds. Eggs detected (percent of herds affected in parentheses) were: strongyle-type (100%), Capillaria sp. (63.6%), Moniezia sp. (54.6%), Nematodirus sp. (50%), Trichuris sp. (40.9%), and Strongyloides sp. (9.1%).

Subglottic stenosis secondary to extramedullary hematopoiesis in a patient with postpolycythemia myeloid metaplasia.

BACKGROUND: Extramedullary hematopoiesis (EMH) is known to occur in myeloproliferative disorders and hemoglobinopathies and is usually seen in the spleen and liver. METHODS: We report the first case of EMH causing subglottic stenosis in a woman with postpolycythemia myeloid metaplasia (PPMM). A tracheotomy was performed to maintain the airway and local radiotherapy was given. RESULTS: Two months after the radiotherapy was completed laryngoscopy showed an unobstructed airway with no evidence of disease, and the patient was successfully decanulated. Magnetic resonance imaging 8 months after radiotherapy confirmed the absence of local disease. CONCLUSION: Consideration should be given to EMH as a possible cause of airway obstruction in the differential diagnosis of a patient with a history of PPMM.

Sinusoidal CD30-positive large B-cell lymphoma: a morphologic mimic of anaplastic large cell lymphoma.

Anaplastic large cell lymphoma (ALCL) has been recognized recently as a distinct clinicopathologic entity, restricted to a subset of CD30-positive diffuse large cell lymphomas of T/null lineage. Some of the characteristic features of ALCL, such as CD30 antigen expression and the presence of large pleomorphic lymphoid cells infiltrating lymph node sinuses, can be found rarely in diffuse large B-cell lymphomas. We collected 11 such cases, and their clinical, morphologic, and immunophenotypic features are reviewed. The age of the patients ranged from 36 to 82 years (mean, 63.2 years) with a male to female ratio of 1:1.2. All neoplasms were nodal with a sinusoidal infiltrative pattern, although four neoplasms also had foci of confluent growth. Eight tumors were composed predominantly of large pleomorphic cells with occasional Reed-Sternberg-like cells. The other three tumors had a higher proportion of large monomorphic lymphoid cells. Necrosis and admixed granulocytes were other common features. Immunophenotypically, all cases were positive for CD30 and CD20 or CD79a. All eight cases examined for anaplastic lymphoma kinase-1 immunoreactivity were negative. In situ hybridization for Epstein-Barr virus RNA was performed in eight cases; two were positive. Excluding one consultation case with no available clinical follow-up data, six patients died of the disease within 3 years and one had disease relapse within 1 year. We conclude that an unusual variant of diffuse large B-cell lymphoma can closely mimic ALCL. However, these neoplasms can be distinguished from ALCL by virtue of their B-lineage and lack of anaplastic lymphoma kinase-1 expression. Evidence of Epstein-Barr virus infection can be found in a small subset of these neoplasms.

Hepatosplenic T-cell lymphoma of alphabeta lineage in a 16-year-old boy presenting with hemolytic anemia and thrombocytopenia.

The authors report an unusual case of peripheral T-cell lymphoma in a 16-year-old boy who presented initially with jaundice, splenomegaly, anemia, and thrombocytopenia. A lymphoma was found subsequently in the spleen, which was infiltrated extensively in the red pulp by medium-sized, blastic-appearing lymphoma cells. Immunologic characterization of these cells revealed positivity for CD3, CD5, CD45RO, CD56, and T-cell intracellular antigen (TIA), and negativity for CD2, CD3, CD4, CD8, CD57, CD34, and terminal deoxynucleotidyl transferase (TdT). Conventional cytogenetic studies revealed the presence of isochromosome 7q. On follow up, this patient deteriorated rapidly, with evidence of liver and bone marrow involvement. Although the overall clinical and pathologic features of this disease were characteristic of hepatosplenic gammadelta T-cell lymphoma, the T-cell receptor of this tumor showed an immunophenotype of alphabeta not gammadelta lineage. Using the Southern blot technique, the authors demonstrated monoclonal gene rearrangement of the T-cell receptor beta-chain. Thus, they confirmed the existence of hepatosplenic alphabeta T-cell lymphoma. In view of its overall similarity to hepatosplenic gammadelta T-cell lymphoma, this unusual entity probably represents a slight biologic variation of the same disease.

Myeloma progenitors in the blood of patients with aggressive or minimal disease: engraftment and self-renewal of primary human myeloma in the bone marrow of NOD SCID mice.

The myelomagenic capacity of clonotypic myeloma cells in G-CSF mobilized blood was tested by xenotransplant. Intracardiac (IC) injection of NOD SCID mice with peripheral cells from 5 patients who had aggressive myeloma led to lytic bone lesions, human Ig in the serum, human plasma cells, and a high frequency of clonotypic cells in the murine bone marrow (BM). Human B and plasma cells were detected in BM, spleen, and blood. Injection of ex vivo multiple myeloma cells directly into the murine sternal BM (intraosseus injection [IO]) leads to lytic bone lesions, BM plasma cells, and a high frequency of clonotypic cells in the femoral BM. This shows that myeloma has spread from the primary injection site to distant BM locations. By using a cellular limiting dilution PCR assay to quantify clonotypic B lineage cells, we confirmed that peripheral myeloma cells homed to the murine BM after IC and IO injection. The myeloma progenitor undergoes self-renewal in murine BM, as demonstrated by the transfer of human myeloma to a secondary recipient mouse. For 6 of 7 patients, G-CSF mobilized cells from patients who have minimal disease, taken at the time of mobilization or after cryopreservation, included myeloma progenitors as identified by engraftment of clonotypic cells and/or lytic bone disease in mice. This indicates that myeloma progenitors are mobilized into the blood by cyclophosphamide/G-CSF. Their ability to generate myeloma in a xenotransplant model implies that such progenitors are also myelomagenic when reinfused into patients, and suggests the need for an effective strategy to purge them before transplant.

Outcome of advanced stage low grade follicular lymphomas in a population-based retrospective cohort.

BACKGROUND: To the authors' knowledge previous reports of patient outcome for advanced stage low grade follicular lymphomas (LGFL) have not been population-based. This is the first report describing the outcome of these patients based on a population-based cohort. METHODS: A retrospective chart review was performed for all patients diagnosed with advanced stage LGFL between 1987-1995 for the adult population of central and northern Alberta, Canada. RESULTS: One hundred and fifty-seven patients were diagnosed with advanced stage LGFL. Approximately 45% of patients had died at last follow-up. Treatment was initiated at the time of diagnosis in 87 patients (55%), with alkylating agents used in 66% of them. Of the 70 patients not treated at the initial diagnosis, 69% had been treated at a median of 16.3 months. The overall median survival was 5.9 years. On univariate analysis, significant variables (P < 0.20) included age, B symptoms, symptomatic lymphadenopathy, symptomatic splenomegaly, splenomegaly, Eastern Cooperative Oncology Group performance status, baseline lactate dehydrogenase (LDH), diffuse component on histology, and treatment at the time of diagnosis. By multivariate analysis, the only factors that influenced survival significantly and independently were baseline LDH and B symptoms. An elevated baseline LDH had a hazard ratio of 2.80 (95% confidence interval [CI], 1.65, 4.74) and a median survival of 8.0 years versus 3.6 years (P < 0.0001). B symptoms had a hazard ratio of 2.30 (95% CI, 1.23, 4.30) and a median survival of 6.5 years versus 3.1 years (P < 0.0067). CONCLUSIONS: Although some patients with advanced stage LGFL enjoy a prolonged survival, 80% of deaths in this cohort were attributable to lymphoma. The median overall survival of 5.9 years offers a less positive perspective on the outcome of these patients than in previous nonpopulation-based reports. This emphasizes the need for further population-based studies as well as new therapeutic approaches, especially those directed toward patients with poor prognostic features such as elevated baseline LDH and B symptoms.

Expression of transmembrane 4 superfamily member, CD9, is related to improved progression-free survival in patients with diffuse non-Hodgkin's lymphoma.

Decreased expression of the transmembrane 4 superfamily member, CD9, is associated with poor prognosis in patients with breast or non-small cell lung cancer. The expression of CD9 in lymphoma was examined in this study. Fifty-one sections with diffuse lymphomas were examined. Thirty-seven had low expression and 14 high expression of CD9. At 5 years the progression-free survival rates were 83.3+/-10.8% and 32.8+/-9.2% (p=0.018), and the actual survival were 83.3+/-10.8% and 56.8+/-8.9% (p=0.256) for those with high and low CD9 expression respectively. Decreased expression of CD9 appears to be a prognostic factor for poor survival in patients with diffuse lymphomas.

Comparison of cytogenetic analysis, southern analysis, and polymerase chain reaction for the detection of t(14; 18) in follicular lymphoma.

This study was undertaken to compare the ability of cytogenetic analysis (CG), Southern analysis (SA) and the polymerase chain reaction (PCR) to detect the t(14; 18) in follicular lymphoma (FL). All methodologies were performed by standard techniques. The probes used for SA included major breakpoint region (mbr) and minor cluster region (mcr) probes. The primers for PCR were identical or similar to those used by other investigators. One hundred fifteen cases of FL were ascertained by morphologic criteria, from which sufficient fresh tissue was available for both CG and molecular analysis. Eleven cases failed by both methods (nonrepresentative sampling). One hundred four cases showed evidence of an abnormal clone by CG and/or immunoglobulin gene rearrangement (IgH) studies. Cytogenetic analysis failed in 2 cases, was positive for t(14; 18) in 91 of the remaining 102 cases (89%) and detected a non-t(14; 18) close in 11 cases. An IgH clonal rearrangement was confirmed in all 104 cases. Southern analysis detected a mbr or mcr rearrangement in 78 of 104 cases (75%). Polymerase chain reaction detected an mbr or mcr rearrangement in 68 of 104 cases (65%). The use of PCR as a clinical test to detect t(14; 18)-positive lymphomas, with single primer sets for the mbr and mcr, will result in a high false-negative rate. The use of additional primers to detect uncommon breakpoints sites will be required to enhance the sensitivity of PCR for detection of t(14; 18) in malignant lymphoma.

Combination of t(14;18) and a Burkitt's type translocation in B-cell malignancies.

The combination of chromosomal translocations associated with bcl-2 rearrangement [t(14;18)] and c-myc rearrangement [t(8;14), t(8;22), or t(2;8)] has infrequently been detected in lymphoproliferative disorders. We have recently identified four cases of a B-cell malignancy exhibiting this dual translocation. In addition to t(14;18), one case had t(8;14) and three had the t(8;22). One case presented as de novo acute lymphoblastic leukemia (ALL-L2), two as de novo high grade lymphomas and the fourth evolved to a "blastic" phase from a previously documented follicular lymphoma. Immunophenotyping and molecular analysis was performed on three of the cases: all were negative for terminal deoxynucleotidyl transferase (TdT) but were CD10 positive. Two of the three cases with t(8;22) were negative for surface immunoglobulin (SIg) and positive for HLA-DR. Rearrangement of the oncogene bcl-2 was identified in a single case by polymerase chain reaction (PCR) only. Similar to cases reported in the literature, all patients had a poor clinical outcome despite aggressive therapy. Dual translocation lymphoid malignancy has a relatively characteristic morphology and the diagnosis should be considered when there is a history of an antecedent low grade lymphoma or when there is discordance between the "blastic" morphology and the immunophenotype (TdT- and/or SIg+). Confirmation requires demonstration of the characteristic translocations. Recognition of this entity has significant clinical implications that may require consideration of alternate treatment strategies.

Detection of micrometastases from primary breast cancer.

The monoclonal antibody LICR-LON-M8 was used in a series of experiments to determine how an immunohistochemical technique could be used as a diagnostic test for micrometastatic disease in patients with operable, primary breast carcinoma. Optimal tissue and antigen preservation was obtained with fixatives containing either picric acid or a heavy metal such as mercury to allow staining with the monoclonal antibody diluted to 1:12,000 to 1:16,000 from unpurified mouse ascites. Tissue affected by primary and metastatic disease stains in a characteristic fashion, which is distinct from benign breast tissue. All the ductal tumours stained positively for malignant cells with the monoclonal antibody preparation. Within the bone marrow, occasional granulocytes and granulocyte precursors stained positively if the endogenous peroxidase activity was incompletely blocked. These cells were readily differentiated from tumour cells on cytologic examination. With these monoclonal antibody and immunohistochemical staining techniques it may now be possible to detect early micrometastatic disease in the bone marrow of patients with primary breast cancer.

Monoclonal antibody LICR-LON-M8 does not predict the outcome of operable breast cancer.

The prognostic value of the monoclonal antibody LICR-LON-M8, which has been shown to detect micrometastatic disease, was evaluated in a prospective, double-blind, clinical study of bone-marrow specimens from patients with operable breast cancer. Four bone-marrow specimens, obtained from each of 50 patients at the time of excision of the primary breast tumour, were examined immunohistochemically, with LICR-LON-M8 as the primary antibody. All of the primary tumour specimens demonstrated positive staining for malignant disease with LICR-LON-M8. The bone-marrow specimens of four patients demonstrated positive staining: three specimens were "suspicious" for malignant cells and one contained definite malignant cells on cytologic examination. This gave a 2% rate of detectable micrometastatic disease at the time the primary tumour was excised. Patient follow-up averaged 21.5 +/- 9.1 months. The test results did not correlate with outcome. A negative test result with LICR-LON-M8 did not imply a better prognosis. The authors conclude that examination of bone-marrow specimens stained with LICR-LON-M8 in patients with operable breast cancer is of no clinical value. Furthermore, the low rate of micrometastases detected is at variance with that reported by others. In view of the natural history of breast cancer, the authors believe that their results were not unexpected and they question the importance of other results.

Consequences of the t(14;18) chromosomal translocation in follicular lymphoma: deregulated expression of a chimeric and mutated BCL-2 gene.

The t(14;18) chromosomal translocation of human follicular lymphoma recombines the candidate transforming gene bcl-2, located at 18q21, with the immunoglobulin (Ig) H-chain joining region (JH) at 14q32. To elucidate the consequences of this translocation, we cloned bcl-2 cDNAs from a pre-B cell line (Nall-1) and a t(14;18) lymphoma cell line (SU-DHL-6) and compared these sequences with their genomic counterparts. These studies revealed the complexity of bcl-2 gene expression in which six potential polyadenylation signals in exon 3 and two different 5' exons (exons 1 and 2) and promoters are alternatively used to generate different sized bcl-2 mRNAs. A single open reading frame (ORF), at the junction of exons 2 and 3, predicts a 239 amino acid, 26 kD protein. Most chromosome 18 breakpoints cluster within a 150 bp region of exon 3. In SU-DHL-6 the t(14;18) translocation juxtaposes a truncated bcl-2 gene with J6 in a tail-to-head configuration, resulting in the deregulated expression of chimeric bcl-2/Ig transcripts. Importantly, the SU-DHL-6 bcl-2 cDNA also contained several point mutations in the ORF, two of which altered the primary amino acid sequence. The deregulated expression of an altered bcl-2 gene may play a critical role in the disordered growth and differentiation of follicular B cell lymphoma.

Angioimmunoblastic lymphadenopathy with dysproteinemia. Circulating immune complexes and the review of 18 cases.

Eighteen patients with angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) have been analyzed by reviewing all available biopsy, laboratory, and clinical data. Because of features suggesting the presence of circulating immune complexes (CIC), CIC serial sample determinations were performed throughout their disease in available patients. Age, sex, and clinical and laboratory characteristics were consistent with previously reported series. Six of 18 (33%) patients having a drug exposure associated with onset or exacerbation of symptoms demonstrated a significantly decreased survival (P less than 0.02). Achievement of complete remission was a significant indicator of longevity (P less than 0.001). Only one patient (6%) developed diffuse histiocytic lymphoma. Elevated CIC were detected in the four patients tested. In two patients fluctuating CIC levels could clearly be correlated to clinical remission or exacerbation. Despite the small number of patients tested, it was concluded tha CIC may provide useful information for therapy selection, prediction of relapse, and further insight into pathogenetic mechanisms in AILD.

The response of an acquired Factor V inhibitor to activated Factor IX concentrate.

A 91-year-old man developed a severe bleeding diathesis postoperatively. Laboratory studies showed an inhibitor to factor V which was identified as IgG. The patient failed to respond to fresh-frozen plasma and platelet transfusions, but demonstrated both clinical and laboratory improvement after transfusion with an activated prothrombin complex concentrate (Autoplex). Patients with refractory inhibitors to factors VIII or IX have been managed successfully with this concentrate; however, this case demonstrates that is also may be of value in managing patients with refractory inhibitors to factor V.