Discordance of ZAP-70 in patients with chronic lymphocytic leukemia.

B-cell chronic lymphocytic leukemia has a highly variable clinical course with behavior ranging from indolent to aggressive. Identified prognostic markers include IgV(H) mutational status, and CD38 and ZAP-70 expression. In several studies, ZAP-70 expression correlated with IgV(H) mutational status, and predicted disease progression and overall survival. In addition to its prognostic utility, ZAP-70 expression was found to be constant over time, and did not vary between peripheral blood, bone marrow or lymph node specimens in individual patients. In contrast to these reports, we present three CLL patients with discordant ZAP-70 levels. One demonstrated a change in expression with time; the second and third cases had discordant results in blood, lymph node and bone marrow and between blood and bone marrow specimens, respectively, obtained at the same time.

A Chinese patient with non-HFE-linked iron overload.

The gene for hemochromatosis (HFE) was recently identified and contains two missense mutations: C282Y and H63D. The C282Y mutation is found homozygous in approximately 85% to 90% of patients of Northern European ancestry with hereditary hemochromatosis. There are no previous reports with results of genetic testing in Chinese patients with regard to iron overload. In this case report, we describe a Chinese woman with marked hepatic iron overload that was nonfamilial, with unusual biopsy findings, in whom neither the C282Y nor the H63D mutations in HFE were found.

Blastic variant of mantle cell lymphoma following interfollicular Hodgkin's lymphoma.

Infrequently, patients are diagnosed with Hodgkin's lymphoma and a morphologically distinct lymphoma. While specific subtypes of lymphomas (including Hodgkin's lymphoma) may present diagnostic difficulties, fine needle aspiration biopsy (FNAB) is sometimes useful in the evaluation and classification of these lymphoproliferative processes. We report a case of the blastic variant of mantle cell lymphoma following Hodgkin's lymphoma, interfollicular variant. A 66-year-old woman with a history of Hodgkin's lymphoma presented with increasing contralateral cervical adenopathy three years after receiving chemotherapy. FNAB with ancillary immunophenotypic characterization identified mantle cell lymphoma, blastic variant. Subsequent excisional biopsy confirmed this diagnosis and also aided in the exclusion of recurrent Hodgkin's lymphoma. In addition to identifying the previously unreported combination of blastic variant of mantle cell lymphoma and Hodgkin's lymphoma, this case emphasizes the utility of FNAB in evaluation of new masses in patient's with a previous diagnosis of Hodgkin's lymphoma.

Primary biliary malignant lymphoma clinically mimicking cholangiocarcinoma: a case report and review of the literature.

Primary lymphomas of the liver and biliary tract are rare tumors. We describe an unusual case of a diffuse large B-cell lymphoma arising in the extrahepatic bile ducts with local extension to involve the intrahepatic bile ducts. The patient presented solely with obstructive biliary symptoms. The clinical presentation, radiographic studies, and gross findings at surgery suggested that this patient had a Klatskin tumor (cholangiocarcinoma arising at the junction of the left and right hepatic ducts). While rare, the difference in initial patient management emphasizes the importance of including malignant lymphoma in the differential diagnosis of obstructive biliary lesions. Ann Diagn Pathol 5:25-33, 2001.

Efficient recovery of DNA from peripheral blood for diagnostic analysis with a vacuum manifold.

BACKGROUND: The increasing clinical use of diagnostic DNA mutation analysis requires efficient isolation of DNA from peripheral blood. METHODS AND RESULTS: The use of a vacuum manifold to isolate DNA was evaluated and compared with a similar centrifugation-based DNA isolation technique. In PCR-based assays of five-point mutations, identical results were obtained with DNA isolated from peripheral blood using either centrifugation or a vacuum system. Minor modifications to PCR procedures were encountered. CONCLUSIONS: In the clinical setting, this vacuum-driven method of DNA isolation provides an efficient, useful alternative to conventional centrifugation-based DNA isolation from peripheral-blood specimens. Providing sufficient, stable DNA for multiple assays, it is easily implemented without highly specialized, expensive equipment and decreases the time spent isolating DNA from multiple samples. In addition, the potential for specimen contamination is reduced because there are fewer transfer steps.

Low-grade B-cell lymphoma and concomitant extensive sarcoidlike granulomas: a case report and review of the literature.

Sarcoidlike granulomas may occur in association with Hodgkin lymphoma and non-Hodgkin lymphoma. The granulomas may be concomitant and so extensive that they obscure the malignant process. In addition, a sarcoidosis-lymphoma syndrome has been described in which there appears to be a relationship between sarcoidosis and the development of a lymphoproliferative disorder. We report a case of a low-grade B-cell lymphoma with concomitant extensive sarcoidlike granulomas. The patient had no diagnostic clinical evidence of sarcoidosis, although she had an elevated serum calcium level and increased serum angiotensin converting enzyme activity. Increased serum calcium and serum angiotensin-converting enzyme activity have been associated with clinical sarcoidosis but have also occasionally been described in association with Hodgkin lymphoma and non-Hodgkin lymphoma without evidence of sarcoidosis. We describe our findings and illustrate the usefulness of immunoperoxidase immunophenotyping techniques in such a case.

CD7 and CD56-positive primary effusion lymphoma in a human immunodeficiency virus-negative host.

Primary effusion lymphoma is an entity with distinctive features. The majority of cases are diagnosed in patients infected with human immunodeficiency virus. We report a case of pleural-based primary effusion lymphoma in an elderly patient negative for human immunodeficiency virus. By flow cytometry, lymphoma cells expressed CD7, CD38, CD45, CD56, HLA-DR, and kappa surface light chains. A monoclonal rearrangement of the immunoglobulin heavy chain and the presence of human herpesvirus 8 genome were detected. Our case lacked CD30 or CD138 with expression of surface light chains. There was strong expression of CD7 and CD56. These findings are unusual or unique in primary effusion lymphoma. Our report suggests that aberrant expression of T cell and natural killer cell markers can be seen in primary effusion lymphoma.

DNA polymerase chain reaction using fine needle aspiration biopsy smears to evaluate non-Hodgkin's lymphoma.

OBJECTIVE: To apply polymerase chain reaction (PCR) analysis to the fine needle aspiration biopsy (FNAB) evaluation of lymphoid proliferations. STUDY DESIGN: We analyzed 37 consecutive archived FNAB malignant lymphoma specimens. Immunophenotypic data from the fine needle aspiration biopsy and excisional biopsy material was available for all specimens. PCR to identify monoclonal rearrangements of the immunoglobulin heavy chain gene, T-cell receptor and translocations involving the bcl-1 and bcl-2 genes was performed. RESULTS: Seventy-eight percent of cases were detected by at least one of these assays. Where DNA analysis was performed on excisional biopsy material, 70% of the cases had identical results; no discordant results for the immunoglobulin heavy chain gene or T-cell receptor were found. In 23% of cases, after review of all available data, a discordant result was thought to be a consequence of a false negative result in DNA analysis of excisional biopsy material. CONCLUSION: These findings indicate that PCR analysis of archived FNAB material, when necessary, provides useful information for diagnosis and staging of malignant non-Hodgkin's lymphomas.

T-cell rich, Ki-1-positive post-transplant lymphoproliferative disorder: a previously undescribed variant following liver transplant.

Post-transplant lymphoproliferative disorders (PTLD) are a consequence of the immunosuppressive therapy following organ transplant. We describe a patient who developed PTLD seven years after liver transplant and while receiving cyclosporine and prednisone. Magnetic resonance imaging demonstrated a paraspinal mass extending from T11 to L1. Microscopically, this was composed of a diffuse infiltrate of small to intermediate sized T-lymphocytes with clusters of large anaplastic tumor cells with amphophilic cytoplasm, large irregular nuclei and prominent nucleoli. A high mitotic rate and atypical mitotic figures were noted in the clusters of large cells. Flow cytometric and immunohistochemical analysis failed identify either a monoclonal B-cell population or a T-cell population with aberrant expression of the T-cell surface markers. Strong positivity for CD30 and focal staining for epithelial membrane antigen (EMA) of the large cells was seen. Leukocyte common antigen (LCA), cytokeratin, vimentin, monocyte/macrophage and B- and T-markers were negative. The small lymphoid cells were positive for CD3, MT-1 and UCHL-1. Based on the immunophenotypic and morphological evaluation, this was characterized as a T-cell rich PTLD. PCR analysis identified a monoclonal population of B-cells. This unusual case emphasizes the morphological and immunophenotypic diversity of PTLD. The utility of PCR analysis in the evaluation of PTLD is also demonstrated.

Leukemic phase of mantle cell lymphoma presenting as anemia: diagnosis by combining flow cytometry and cytomorphology.

We report a case of mantle cell lymphoma in leukemic phase, which was diagnosed by a bone marrow biopsy performed as part of a workup for chronic anemia in a patient without lymphadenopathy. The patient, a 79-year-old man with diabetes mellitus, hypertension, chronic renal failure, congestive heart failure, and atherosclerosis, presented with claudication. On admission, he also had an 8-month history of anemia, during which time he experienced a 18-kg weight loss. On presentation, the patient had normal vital signs, anemia, leukocytosis (as well as an absolute lymphocytosis), and splenomegaly; as mentioned, lymphadenopathy was absent. A bone marrow biopsy showed an increase in small to intermediate-sized, slightly irregular lymphocytes in interstitial nodules. Flow cytometric immunophenotyping of the bone marrow identified a monoclonal population of cells, representing 25% of cells within the bone marrow, with expression of CD19, CD20, immunoglobulin M/D, lambda light chain, HLA-DR, and CD5; reactions for CD10 and CD23 were absent. Based on morphologic and immunophenotypic analysis of the bone marrow, as well as morphologic review of the peripheral blood smear, a diagnosis of mantle cell lymphoma involving the bone marrow and in leukemic phase was made. Subsequent polymerase chain reaction analysis of DNA from peripheral blood identified a population of cells with the bcl-1 rearrangement. This case is unique in that the diagnosis of mantle cell lymphoma was made without lymph node or spleen analysis and the patient, although exhibiting bone marrow and peripheral blood involvement by mantle cell lymphoma at presentation, did not have lymphadenopathy.

Combined fine needle aspiration biopsy, and immunophenotypic and genotypic approach to posttransplantation lymphoproliferative disorders.

OBJECTIVE: To report our experience with a combined approach to posttransplant lymphoproliferative disorders (PT-LPDs) that utilizes fine needle aspiration biopsy. STUDY DESIGN: A review of the files in the Department of Pathology, Saint Louis University Health Sciences Center; from 1988 to 1996 identified six patients with a diagnosis of PT-LPD who underwent either percutaneous or radiologically guided fine needle aspiration biopsy (FNAB). In all cases, material was collected for cytomorphology, flow cytometric analysis and, in selected cases, DNA polymerase chain reaction (PCR). Subsequent evaluations and clinical outcomes were obtained from the medical record. RESULTS: The six transplant recipients (4 men and 2 women; 3 cardiac, 2 renal and 1 hepatic transplant) had an age range of 16-65 years. The aspirate material on these six patients had a polymorphic pattern of lymphoid cells with varying sizes. By flow cytometry, two were monoclonal, while four had a polyclonal pattern. DNA PCR analysis on two FNABs demonstrated a monoclonal rearrangement of the immunoglobulin heavy chain gene. CONCLUSION: FNAB provides cytomorphologic characterization of PT-LPDs in transplantation patients and sufficient material for successful use of flow cytometry immunophenotyping and DNA PCR analysis. FNAB, therefore, has an important role in the evaluation of organ transplantation patients and is a valuable tool for assessing and diagnosing PT-LPD.

Lymphocyte-depleted Hodgkin's disease: diagnostic challenges by fine-needle aspiration.

The diagnosis of Hodgkin's disease by fine-needle aspiration (FNA) can be problematic. A case of Hodgkin's disease, lymphocyte depleted subtype, sample by FNA biopsy is presented. We describe the cytomorphologic features present in this unusual subtype of Hodgkin's disease and discuss the differential diagnosis. Immunohistochemical and morphologic findings of a subsequent biopsy specimen supported the diagnosis. Although FNA is an increasingly used diagnostic modality to evaluate tumors including malignant lymphomas, Hodgkin's disease remains, as in this case, a difficult diagnosis by FNA.

bcl-1 translocations are frequent in the paraimmunoblastic variant of small lymphocytic lymphoma.

To evaluate the usefulness of polymerase chain reaction analysis of translocations involving the bcl-1 and bcl-2 genes in variants of CD5-positive B-cell lymphomas, we analyzed four cases classified as the paraimmunoblastic variant of small lymphocytic lymphoma. This neoplasm, originally identified as an aggressive, diffuse, B-lineage lymphoma related to small lymphocytic lymphoma, can be confused with variants of mantle cell lymphoma (an immunophenotypically and morphologically similar neoplasm). No translocations involving bcl-2 and the immunoglobulin heavy chain gene were identified; two cases had translocations involving the bcl-1 and the immunoglobulin heavy chain genes. The frequency of finding this translocation suggests that these categories of neoplasms might be extremely difficult to distinguish or that a closer relationship between these neoplasms exists than was initially proposed.

Secondary pleural involvement by an AIDS-related anaplastic large cell (CD30+) lymphoma simulating metastatic adenocarcinoma.

We report a patient with acquired immunodeficiency syndrome with secondary pleural and pulmonary involvement by a CD30+ anaplastic large cell lymphoma (ALCL) that morphologically simulated metastatic adenocarcinoma. We describe the morphologic findings in order to heighten awareness that CD30+ ALCL may mimic metastatic adenocarcinoma in a body fluid or bronchial brushing and should be considered in the differential diagnosis. Primary body cavity based (PCBC) AIDS-related lymphoma is a relatively newly described disease entity with morphologic features bridging ALCL and large cell immunoblastic lymphoma with a CD30+ null immunophenotype. A morphology mimicking adenocarcinoma has not been previously described in this entity but should be considered in a patient with AIDS presenting exclusively with a serous effusion. Appropriate immunoperoxidase staining should aid in these differential diagnoses.

Incidental early detection of a splenic marginal zone lymphoma by polymerase chain reaction analysis of paraffin-embedded tissue.

Splenic marginal zone lymphoma (SMZL) most commonly presents with splenomegaly and stage IV disease. To our knowledge, there have been only two reported cases of SMZL without associated splenomegaly; one was detected incidentally after a bicycle accident. This previously reported case represented an early-stage SMZL with monoclonality confirmed by immunohistochemistry. We report a case of early-stage SMZL detected incidentally following a motor vehicle accident; monoclonality was confirmed by polymerase chain reaction analysis of paraffin-embedded tissue owing to the inability of confirmation by immunohistochemical techniques. We describe our findings and emphasize the importance of recognizing early stages of SMZL in incidental splenectomies by polymerase chain reaction analysis of paraffin-embedded tissue. Frozen tissue is not generally available in such cases.

Rapid and effective processing of blood specimens for diagnostic PCR using filter paper and Chelex-100.

AIM: To provide a more efficient method for isolating DNA from peripheral blood for use in diagnostic DNA mutation analysis. METHODS: The use of blood impregnated filter paper and Chelex-100 in DNA isolation was evaluated and compared with standard DNA isolation techniques. RESULTS: In polymerase chain reaction (PCR) based assays of five point mutations, identical results were obtained with DNA isolated routinely from peripheral blood and isolated using the filter paper and Chelex-100 method. CONCLUSION: In the clinical setting, this method provides a useful alternative to conventional DNA isolation. It is easily implemented and inexpensive, and provides sufficient, stable DNA for multiple assays. The potential for specimen contamination is reduced because most of the steps are performed in a single microcentrifuge tube. In addition, this method provides for easy storage and transport of samples from the point of acquisition.

Cytologic findings in a case of T-cell rich B-cell lymphoma: potential diagnostic pitfall in FNA of lymph nodes.

Fine-needle aspiration biopsy (FNAB) is a reliable diagnostic technique for most palpable masses. This technique is utilized routinely to diagnose metastatic carcinoma and melanomas in lymph nodes. However, the role of FNAB in the investigation of lymphoproliferative lesions is still controversial. Recent publications have supported the use of FNAB cytology, in conjunction with immunophenotyping, as an accurate, reliable diagnostic modality for the classification of most lymphomas (Sneige et al., Acta Cytol 1990; 34:311-322; Skoog and Tani, Diagn Oncol 1991; 1:12-18; Robins et al., Am J Clin Pathol 1994; 101:569-576; Katz, Clin Lab Med 1991; 11:469-499). We present a case of a T-cell rich, large B-cell lymphoma. Material obtained by FNAB mimicked a reactive process by both cytomorphological and immunophenotypical analysis. This case demonstrates a potential pitfall in the use of FNAB to evaluate lymphoproliferative disorders even when used in conjunction with immunophenotypic studies. The case also emphasizes the need for detailed clinical and prior pathologic information when a cytologic sample is being evaluated for a lymphoproliferative disorder. To our knowledge, the cytomorphologic findings of this particular type of lymphoma have not been previously described as seen on an FNAB.

Bilateral mucosa-associated lymphoid tissue lymphomas of parotid glands: a 13-year interval.

Benign lymphoepithelial lesions of salivary gland may have a population of monoclonal B cells. There is controversy regarding the clinical significance of monoclonality in these lesions. Morphologically and clinically, benign lymphoepithelial lesions of the salivary gland with monoclonal B cells falls within the spectrum of low-grade B-cell lymphomas of mucosa-associated lymphoid tissue. We report a case of bilateral parotid lymphomas of mucosa-associated lymphoid tissue, separated diagnostically by a 13-year interval. Polymerase chain reaction analysis detected similar clones in the bilateral parotid glands. This finding supports the natural history of mucosa-associated lymphoid tissue lymphomas. In addition, because mucosa-associated lymphoid tissue lymphomas have an unpredictable period of localized disease, recognition of monoclonality in benign lymphoepithelial lesions of salivary glands is important for local cure and can be aided by combining histologic with immunohistochemical, flow cytometric immunophenotyping, and Southern blot and/or polymerase chain reaction analysis.

Synthesis of elastin by pleomorphic adenomas.

Previous morphologic and histochemical studies have documented extracellular elastin and elastic fibers within the matrix of pleomorphic adenomas of the salivary glands. By morphologic criteria, the elastin appeared to be synthesized by the tumor rather than being a consequence of stroma produced in response to the tumor cells. To examine this issue, nine pleomorphic adenomas were studied by immunohistochemistry and in situ hybridization with tropoelastin-specific antibodies and complementary DNAs. Corroborating the previous morphologic studies, immunohistochemistry demonstrated abundant extracellular elastin within the matrix of pleomorphic adenomas. Additionally, both immunohistochemistry and in situ hybridization demonstrated continued synthesis of tropoelastin by the neoplastic cells. Tropoelastin production was seen in neoplastic cells with all morphologies.