伴EB病毒感染的淋巴瘤继发噬血细胞综合征四例

目的 探讨伴EB病毒(EBV)感染的淋巴瘤继发噬血细胞综合征(HPS)的临床特征.方法 分析4例伴EB病毒感染的淋巴瘤继发HPS患者的临床资料,并文献复习.结果 3例患者初诊为EBV继发HPS,4例患者最终均诊断为T细胞淋巴瘤.临床共同特点为发热、脾大、全血细胞减少、铁蛋白升高和低纤维蛋白原血症,浅表淋巴结肿大不明显,3例患者存在肝功能异常.4例患者抗EBV治疗后EBV-DNA均无明显下降.4例患者采用甲泼尼龙联合环孢素、依托泊苷或氟达拉滨治疗HPS,其中1例患者在激素减量过程中复发,规范化疗后HPS得以控制.结论 伴EBV感染的淋巴瘤继发HPS易被误诊为单纯EBV感染继发HPS.临床抗病毒效果欠佳或治疗过程中出现HPS反复需要警惕潜在淋巴瘤可能,需要多次取材送病理检查,甚至进行PET-CT检查积极寻找原发病,此类疾病的治疗原则是在积极治疗控制HPS后立即开始针对淋巴瘤的规范化疗.     

两种组织脱钙法对免疫组织化学染色影响比较

目的:了解1%(体积分数)盐酸和10%(体积分数)硝酸脱钙液对多种抗原免疫组织化学染色效果的影响.方法:选择伴有灶状钙化的软组织标本包括甲状腺乳头状癌、乳腺癌、前列腺癌、结肠癌和淋巴结各3例,骨组织标本包括活检和尸检病例共9例,将样本分为3组,一组分别用10%(体积分数)硝酸处理24、42和48 h,另一组分别用1%(体积分数)盐酸处理1、2和3 h,还有一组不用酸处理作为对照组,同时进行多种抗原免疫组织化学染色,其中乳腺癌组织作ER、PR和Ki-67染色,甲状腺癌组织作TTF-1染色,前列腺癌作34βE12和P504s染色,结肠癌作AE1/AE3、P504s和Ki-67染色,淋巴结作CD3、CD20和Ki-67染色,骨组织作CD3、CD20、CD68、CD235a、MPO、Ki-67、AE1/AE3和TTF-1染色.结果:伴有钙化的软组织和骨组织内多种抗原免疫组织化学染色阳性程度均随酸处理时间的延长而有不同程度的下降,骨组织对酸处理的耐受力比软组织强;不同抗原对酸处理的敏感性不同,TTF-1和Ki-67最为敏感,ER、CD3、和CD20耐受性较好.结论:大多数情况下,盐酸和硝酸处理都会降低组织免疫组织化学染色的敏感性,但是对不同抗原的影响程度不同.大块骨组织可以采用10%(体积分数)硝酸脱钙,软组织比例较高的骨组织和骨髓活检组织尽可能使用1%(体积分数)盐酸脱钙.     

系统性间变性大细胞淋巴瘤骨髓累及的临床病理学研究

目的 探讨系统性间变性大细胞淋巴瘤(S-ALCL)骨髓累及的临床病理学特点、免疫学表型及临床生物学行为.方法 回顾性分析34例S-ALCL病例资料,进行骨髓活检(19例)或涂片(15例).其中ALK(+)24例,ALK(-)10例.HE染色、免疫组织化学染色观察病理形态及免疫表型,原位杂交法检测EB病毒.结果 6例(17.6%)S-ALCL存在骨髓累及,均经骨髓活检标本确定,15例患者骨髓涂片中均未见肿瘤累及.ALK(+)ALCL和ALK(-)ALCL骨髓累及的发生率分别为16.7%(4/24)和20.0%(2/10),差异无统计学意义(P=0.3555).与无骨髓累及病例比较,骨髓累及病例的年龄、性别分布差异无统计学意义(P值分别为0.8089和0.3085).骨髓累及者肿瘤细胞以间质性分布为主[83.3%(5/6)].生存分析统计提示伴有骨髓累及的患者预后明显差于无骨髓累及者(P=0.0407).结论 S-ALCL骨髓累及发生率低,与患者的发病年龄、性别及ALK蛋白的表达无相关性.伴有骨髓累及的S-ALCL患者临床预后差,骨髓活检在判断S-ALCL预后中有重要意义.     

成年人噬血细胞综合征四例并文献复习

目的 研究成年人噬血细胞综合征(HPS)的临床特征、国际最新HPS-04治疗方案及其与预后的关系.方法 回顾性分析经临床特征、骨髓穿刺结果证实的4例成年HPS患者的治疗经过和临床效果结果 4例成年HPS患者虽经积极规范治疗,但皆病情恶化.结论 HPS患者病情凶险,进展快,应提高警觉,争取较好疗效.     

急性全髓增殖症伴骨髓纤维化一例并文献复习

目的 探讨急性全髓增殖症伴骨髓纤维化(APMF)临床特点,提高对该病的认识。方法结合文献复习对1例APMF患者的临床资料进行分析,为该病的诊断和鉴别诊断提供思路。结果APMF起病急,进展较快,以贫血、出血、感染为主要临床表现,脾大不明显,外周血呈全血细胞减少,可见原始细胞,红细胞形态多正常;骨髓穿刺易干抽,骨髓活检示骨髓中粒系、红系、巨核系三系增殖异常,可见病态造血,伴有显著骨髓纤维化。结论APMF是一种全髓增殖伴有明显骨髓纤维化的疾病,由于骨髓纤维化引起的骨髓液抽吸困难,故诊断有赖于骨髓活组织检查。     

芯针穿刺活检在恶性淋巴瘤诊断中的应用

目的:探讨芯针穿刺活检诊断恶性淋巴瘤的临床应用价值,阐明其有效性.方法:采用HE和免疫组织化学染色方法,对88例芯针穿刺活检诊断为恶性淋巴瘤及淋巴组织非典型增生的病例进行回顾性研究,观察芯针穿刺活检诊断的准确率.结果:本组患者穿刺活检诊断恶性淋巴瘤的准确率为87.5%(77/88),恶性淋巴瘤90%(70/77)可区分组织类型.诊断为淋巴组织非典型增生11例,其中5例通过手术切除活检确诊为恶性淋巴瘤,6例不能明确诊断.在住院患者中,恶性淋巴瘤诊断的准确率为91%(53/58).结论:芯针穿刺活检是诊断恶性淋巴瘤可靠的方法,绝大多数患者可得到明确的分类.     

噬血细胞综合征患者血清血小板生成素水平的研究

目的 探讨血清血小板生成素(TPO)在噬血细胞综合征(HPS)患者中的表达水平及其临床意义.方法 收集2008年9月至2010年7月经首都医科大学附属北京友谊医院确诊的HPS患者26例,根据不同病因分为感染相关性HPS、肿瘤相关性HPS和风湿免疫病相关性HPS,同时收集26名健康人血清,分别采用酶联免疫吸附(ELISA)方法检测其血清TPO水平,并与各实验室检查指标进行相关性分析.结果 HPS患者组血清TPO水平显著低于健康对照组,差异有统计学意义(P=0.001),对HPS患者组中不同病因人群进行单因素方差分析,差异无统计学意义(P=0.183).检测HPS患者血清TPO水平与采血当日血小板、红细胞、血红蛋白、血肌酐、尿素氮、三酰甘油、纤维蛋白原、铁蛋白、NK细胞活性、sCD25水平的相关性,发现其与血肌酐水平呈正相关关系,与其他各项实验室指标均无相关性.结论 TPO可能与各种细胞因子一起影响了HPS患者血细胞的生成,TPO水平降低可能与HPS患者肝功能损害有关,其深层机制还有待进一步探讨.     

无骨髓及血液累及的皮肤原发B淋巴母细胞淋巴瘤一例并文献复习

目的 提高对不伴有外周血及骨髓累及的皮肤原发B淋巴母细胞淋巴瘤(B-LBL)的认识.方法 报道1例罕见的无骨髓血液累及的皮肤原发B-LBL病例的诊断和鉴别诊断过程,并结合文献复习讨论.结果 患者经手术切除行病理组织学活检和免疫组织化学检测示瘤细胞TdT+、CDd+79a、PAX5+,确诊B-LBL;遂榆杳外周血及骨髓,提示均无异常改变.诊断为皮肤原发的B-LBL.结论 皮肤原发B-LBL可不伴有外周血和骨髓病变,易造成临床误诊,需引起病理医生和外科医生的重视.     

原发系统性间变性大细胞淋巴瘤临床病理特征及免疫表型分析

目的 分析原发系统性间变性大细胞淋巴瘤( ALCL)的临床病理特征和免疫组织化学特点,提高诊治水平。方法选取22例ALCL患者,均进行分期、国际预后指数(IPI)、乳酸脱氢酶(LDH)检测,应用免疫组织化学SP法检测间变性淋巴瘤激酶(ALK)、Ki-67、Caspase-3、CD30、EMA、Granzyme B等,回顾性分析患者临床、病理形态学资料、免疫表型及生物学特性,并进行预后分析。结果22例均为原发系统性ALCL,ALK+ 15例(68.2％),ALK-7例(31.8％);AILK+患者发病年龄、Ki-67增殖指数较ALK-患者低,Caspase-3表达率高,差异有统计学意义(x2 =4.618,P= 0.032);15例ALK+ALCL均表达CD30和EMA。ALCL中ALK的表达与Ki-67、Caspase-3的表达呈负相关(r= -0.581,P= 0.006;r=0.458,P=0.032)。ALK+病例较ALK-病例GranzymeB(x2=0.11,P=0.74)、TIA-1( x2= 0.01,P=0.92)的表达率高,但差异无统计学意义(P＞0.05)。有效率为54.5％(12/22),其中完全缓解率为18.2％(4/22);全组中位生存期12个月,1年生存率为59.1％( 13/22),2年生存率为50.0％(11/22)。Ann Arbor分期、LDH及IPI与疾病预后相关。结论ALK+较ALK-ALCL患者核增殖低,恶性程度低,临床特征和免疫表型具有一定的特征性;ALK、Ki-67、Caspase-3、分期、血清LDH及IPI对预测ALCL患者的生存和指导治疗有帮助。     

噬血细胞性淋巴组织细胞增生症六例

目的 提高对噬血细胞性淋巴组织细胞增生症(HLH)诊断及治疗的认识.方法 总结6例HLH患者的临床特征、诊断依据、治疗方案及疗效,并进行分析讨论.结果 HLH常见的临床表现包括发热、肝脾大及血细胞减少,实验室检查异常包括高三酰甘油血症、低纤维蛋白原血症、肝功能异常、黄疸、转铁蛋白升高、低钠血症,骨髓涂片可见噬血细胞.接受包含依托泊苷的化疗方案在疗程的早期有效,但疗效短暂.结论 HLH病情凶险,预后差,提高对HLH的临床表现及实验室特征的认识,有利于加强HLH的早期诊断和治疗,依据HLH-2004治疗指南可以提高患者生存率,但造血干细胞移植仍是目前唯一能使患者获得长期缓解及治愈的有效措施.     

Hemophagocytic syndrome in five patients with Epstein-Barr virus negative B-cell lymphoma

BACKGROUND: The recent recognition of the association of Epstein-Barr virus (EBV) with T-cell/natural killer cell (T/NK-cell) lymphoma has documented that particular types of EBV-containing T/NK-cell lymphoma are frequently complicated by hemophagocytic syndrome (HPS). This observation suggests that both EBV and proliferating T/NK-lymphoma cells play significant roles in the development of HPS. Cytokines released from neoplastic T cells are presumed to account for the activation of macrophages, which is followed by a complex cascade of cytokine production, resulting in full-blown HPS. Five patients with B-cell lymphoma complicated by HPS were studied for elevated serum cytokines, the association of EBV, and CD25 expression of lymphoma cells; the aim of this study was to verify whether the mechanisms of HPS development hypothesized for T/NK-cell lymphoma also operate in B-cell lymphoma. METHODS: Sera were analyzed for the presence of inflammatory and immunoregulatory cytokines. Flow cytometry, immunohistology (IH), in situ hybridization (ISH), polymerase chain reaction (PCR), and Southern blot analysis were performed using bone marrow aspirates, biopsy specimens, and autopsy specimens. RESULTS: Immunophenotypic and Southern blot studies verified that the lymphoma cells of all five patients were of B-cell lineage. Bone marrow aspirates demonstrated histiocytosis with extensive hemophagocytic activity. Marked elevation of serum cytokines and expression of CD25 were observed in all five patients. However, the results of PCR, ISH using EBER1 probe, and IH for latent membrane protein indicated that these lymphoma cells were free of EBV infection. CONCLUSIONS: In patients with B-cell lymphoma, EBV infection is not necessarily required for the initiation of HPS. In this article, the pathogenesis of HPS assumed to be operative in B-cell lymphoma is discussed with reference to T/NK-cell lymphoma complicated by HPS.     

Reactive hemophagocytic syndrome: a new presentation of disseminated histoplasmosis in patients with AIDS

We report the cases of six patients with AIDS in whom reactive hemophagocytic syndrome (RHPS) secondary to disseminated histoplasmosis was diagnosed. RHPS was diagnosed by established criteria, including fever (duration of > or = 7 days, with peak temperatures of > 38.5 degrees C), unexplained thrombocytopenia with anemia and/or neutropenia, and bone marrow biopsy findings of hemophagocytic histiocytosis. Disseminated Histoplasma capsulatum infection was diagnosed on the basis of the results of cultures of the bone marrow sample. The serum lactate dehydrogenase (LDH) level was elevated (> 1,000 IU/L) in all patients, and five of six patients had hyperferritinemia (range of ferritin level, 15,848-425,984 ng/mL). Five patients had features resembling severe sepsis with multiorgan dysfunction. Three patients recovered, and the findings of RHPS resolved following therapy with amphotericin B. In patients with AIDS, the combination of fever, cytopenia, elevated serum LDH level (> 1,000 IU/L), and/or hyperferritinemia (ferritin level of > 10,000 ng/mL) is a clue to the diagnosis of RHPS and disseminated histoplasmosis; bone marrow biopsy is valuable in establishing the diagnosis.     

Epstein-Barr virus associated natural killer cell leukemia: report of an autopsy case

A 20-year-old female was admitted because of high fever, hepatosplenomegaly, severe hepatic dysfunction and coagulopathy. Peripheral blood showed pancytopenia and granular lymphocytes bearing the natural killer cell phenotype (CD2+CD3-CD16+CD56+CD57-TCR alpha beta-TCR gamma delta-) constituted 97% of leucocytes. Southern blot analysis of DNA obtained from peripheral blood mononuclear cells showed germ-line configuration of TCR beta, gamma and delta chain genes. EBV-DNA was detected in a single episomal form by using EBV-terminal repeat probe. Bone marrow findings were consistent with hemophagocytic syndrome and administration of VP-16 was effective transiently. After ten months she died from massive gastrointestinal bleeding. An in situ hybridization study identified EBV-RNA (EBER-1) in atypical lymphocytes infiltrating bone marrow, spleen and lymph nodes. Sections of liver showed steatosis and infiltration of T cells (CD3+ and EBER-1-negative) in the portal areas and few atypical lymphocytes in sinusoids. The patients developed an EBV-associated clonal proliferation of natural killer (NK) cells, but the clinical features were suggestive of chronic active EBV infection or virus-associated hemophagocytic syndrome (VAHS) rather than leukemia. Bone marrow transplantation for NK cell leukemia is an issue to be discussed.     

Presence of Epstein-Barr virus in lymphoepithelioma-like carcinoma of the middle ear

AIM: To examine the association of Epstein-Barr virus (EBV) with carcinoma of the ear. METHODS: Five non-keratinising squamous cell carcinomas and two undifferentiated carcinomas of the ear were examined. In situ hybridisation was used to localised EBV-encoded RNAs (EBER). Immunohistochemical methods to detect LMP-1 and EBNA2 were performed in the EBER positive cases. RESULTS: Two cases were EBER positive, including one non-keratinising and one undifferentiated carcinoma. Both showed identical morphology to those arising from the nasopharynx, with abundant lymphoid stroma. They were both negative for LMP-1 and EBNA2. CONCLUSIONS: EBV associated carcinoma with the morphology of lymphoepithelioma can also arise from the middle ear.     

Granulocytic sarcoma of the jejunum: a rare cause of small bowel obstruction

We report the case of a 40-yr-old man presenting with symptoms of small bowel obstruction. Small bowel x-rays revealed a stricture of the mid-jejunum. Push enteroscopy found a polypoid mass at 1 meter of the ligament of Treitz. Histopathological examination of the biopsy and surgical specimens showed a diffuse infiltrate of the mucosa made of medium to large cells, which were stained on immunohistochemistry by the leucocyte marker CD45 and the histiocyte/monocyte marker CD68 but were negative for the B and T cell markers. Cytological examination of the ascitic fluid revealed many myelobasts with cytoplasmic Auer rods and positive myeloperoxidase staining. There was no evidence of blood or bone marrow involvement suggestive of acute leukemia or myeloproliferative disorders. These findings were consistent with the diagnosis of preleukemic granulocytic sarcoma (or chloroma). Chemotherapy led to complete remission, but 21 months later the patient developed an acute myeloid leukemia. He died from aspergillus pneumonitis, 10 months after bone marrow allograft. Preleukemic granulocytic sarcoma of the small bowel is a rare condition and its diagnosis is usually not easy, requiring histochemical or immunohistochemical studies. Most cases have progressed to acute myeloid leukemia.     

Useful panel of antibodies for the classification of acute leukemia by immunohistochemical methods in bone marrow trephine biopsy specimens

To evaluate the feasibility of acute leukemia typing on routinely processed bone marrow biopsy specimens, 72 cases of previously established acute leukemia covering the spectrum of 17 known subtypes were studied immunohistochemically. Most leukemic myeloblasts were positive for myeloperoxidase in 16 (84%) of 19 cases of acute myeloid leukemia, M1-M4, and M6. Most leukemic cells in 11 of 12 M4 and M5 cases were positive for CD68 (PG-M1). All six M6 cases stained with hemoglobin. Leukemic megakaryoblasts in three of four M7 cases were positive for factor VIII-related antigen. Almost all leukemic cells of 8 T-lineage acute lymphoblastic leukemia (ALL) and 19 B-lineage ALL cases were positive for CD3 and CD79a (HM57), respectively. Staining with CD20 (L26) was positive in the more differentiated B-lineage ALL cases and strongest in L3. Immunohistochemical typing of acute leukemia is possible for most types using this panel of cell lineage-specific antibodies.     

Increased splanchnic blood flow after hypoglycaemia in diabetic and normal man: evidence against glucagon as a mediator

Analysis of non-Hodgkin lymphoma (NHL) involvement of bone marrow trephine biopsy specimens by morphologic features and immunohistochemistry is often difficult, and the criteria for involvement are ill defined. We compared the morphologic and immunohistochemical analysis of B-cell NHL involvement with immunoglobulin heavy chain gene (IgH) rearrangement analysis by polymerase chain reaction (PCR) amplification of the complementarity determining region 3 (CDR3) in bone marrow biopsy specimens from patients with mantle cell lymphoma (n = 53) or hairy cell leukemia (n = 71). By combing morphologic features and phenotype, 54 specimens were considered positive, 62 negative, and 8 inconclusive. PCR analysis showed clonal IgH rearrangements in 46 positive and 6 inconclusive specimens. No clonal IgH rearrangements were present in 61 negative specimens. The 1 false-positive and most false-negative PCR results were likely due to sampling error or DNA degradation of the fixed tissues. In most cases, bone marrow involvement by NHL can be identified by histologic and immunohistochemical examination. Furthermore, clonality of the B-cell population can be detected by amplification of the IgH CDR3 on DNA extracted from bone marrow trephine biopsy sections, which can be helpful in cases diagnosed as inconclusive.     

Detection of Epstein-Barr virus in transformations of low-grade B-cell lymphomas after fludarabine treatment

Fludarabine is a highly effective chemotherapeutic agent for chronic lymphocytic leukemia/small lymphocytic lymphoma and is also active in other B-cell lymphoproliferative disorders. Although highly efficacious in destroying the malignant B-cells, fludarabine also causes T-cell lymphopenia and immunosuppression. We present five patients given fludarabine for low-grade B-cell lymphoproliferative disorders who showed transformation of the primary neoplasm to a higher grade tumor. Immunohistologic antibody studies were performed on paraffin-embedded tissue sections of the initial tissue (when available) and on the follow-up biopsy specimens for CD20, CD3, CD45RO, CD43, CD30, CD15, and latent membrane protein (LMP-1) for Epstein-Barr virus (EBV). The initial diagnoses in these five patients included chronic lymphocytic leukemia/small lymphocytic lymphoma (three cases), follicle center lymphoma (one case), and Waldenstrom's macroglobulinemia (one case). All of the follow-up biopsy specimens showed scattered Hodgkin's-like cells, and two of the five also showed foci of large-cell transformation. The Hodgkin's-like cells showed CD30 immunoreactivity in four of the five cases and CD15 immunoreactivity in three of the five. Strong immunoreactivity of the large, atypical, Hodgkin's-like cells for LMP-1 of EBV was noted in four cases; in the remaining case, this finding was equivocal. In situ hybridization for EBV-encoded RNA was positive in four of the five cases. Molecular studies by polymerase chain reaction (PCR) showed the presence of EBV in three of the five cases. PCR for detection of immunoglobulin heavy chain demonstrated identical monoclonal rearrangements in the original lymphoma and transformation in one case with available material. The CD4 lymphocyte count in each patient was less than 550/microL, indicating cellular dysfunction. Transformation of low-grade non-Hodgkin's lymphomas after fludarabine therapy might be associated with EBV and severe immunosuppression.     

Clonal karyotype abnormalities in EBV-associated hemophagocytic syndrome

BACKGROUND AND OBJECTIVE: An EBV-associated hemophagocytic syndrome (HS) in previously healthy children or young adults has been documented in Taiwan. The exact nature of this syndrome, i.e., either an infectious process or a neoplastic disease, remains to be clarified. METHODS: Three patients diagnosed as having HS were studied retrospectively. Chromosomes from bone marrow were examined by a conventional trypsin-Giemsa banding technique and karyotyped at the beginning of diagnosis or during treatment. In situ hybridization studies for EBV using EBER1 were performed. RESULTS: All three patients presented the classic manifestations of HS including fever, splenomegaly, jaundice, pancytopenia and coagulopathy. Bone marrow aspiration revealed atypical lymphocyte and histiocyte infiltration with hemophagocytosis. EBV genomes were found in bone marrow in all patients. In addition to normal mitotic cells, clonally karyotypically abnormal cells were demonstrated in all three patients whose diseases were rapidly progressive and eventually refractory to etoposide-based therapy. The consistent karyotypical abnormality of add(9)(p24) was noted in two of them. INTERPRETATION AND CONCLUSIONS: Although HS is usually considered a reactive process, the emergence of clonal cytogenetic abnormalities should be considered a malignant entity and treated with more intensive chemotherapy. A large series of cytogenetic and molecular studies is needed to clarify the exact nature of this fatal disease.