中枢神经系统血管内ALK阳性间变性大细胞淋巴瘤一例并文献复习

目的 报道1例血管内间变性大细胞淋巴瘤激酶阳性(ALK+)间变性大细胞淋巴瘤(ALCL),提高对血管内淋巴瘤(IVL)的认识.方法 分析1例中枢神经系统血管内ALK+ALCL的临床资料、组织病理学特点和免疫表型,并结合文献进行复习.结果 患者女性,41岁.CT示右侧顶枕叶不规则低密度灶,增强扫描壁结节及边缘明显强化;磁共振(MRI)示右顶枕叶斑片状不规则异常信号影,累及右侧胼胝体压部,增强扫描呈斑片状不规则强化.血常规示单核细胞比例增高,红细胞压积减少.光学显微镜下观察:脑实质小血管管腔内多量明显异型性大单核细胞,肿瘤细胞胞质丰富嗜伊红,核圆形或不规则,可见马蹄形或肾形核,核仁清楚.免疫组织化学:肿瘤细胞LCA(+)、CD,(+)、ALK-1(+)、EMA(+)、粒酶B(+)、CD20(-)、CD79a(-)、CD30(-)、CD56(-)、GFAP(-)、AE1/AE3(-)、HMB45(-),血管内皮细胞CD31(+)、CD34(+).患者手术后8个月死亡,未行放化疗.结论 血管内ALK+ ALCL是IVL的一种罕见亚型,细胞形态特点及免疫表型类似于淋巴结或结外ALCL,临床症状无特异性,预后差,确诊主要依靠组织病理学检查.     

系统型间变性大细胞淋巴瘤30例临床分析

目的 探讨系统型间变性大细胞淋巴瘤(S-ALCL)的临床特征和预后相关因素.方法 回顾性分析30例S-ALCL患者的临床资料.30例患者均以联合化疗为主,配合局部病灶野放疗8例.化疗方案主要为CHOP、EPOCH、Hyper-CVAD,以CHOP方案为主.结果 30例S-ALCL患者中位年龄36岁,男女比例为1.5∶1,有B症状、Ⅲ～Ⅳ期和结外侵犯者分别占60.0%(18/30)、73.3%(22/30)和60.O%(18/30);乳酸脱氢酶(LDH)升高者占46.7%(14/30);间变性大细胞淋巴瘤激酶(ALK)+18例(60.0%),其发病年龄小于ALK-者(u=3.92,P=0.001).单因素分析显示ALKˉ及LDH升高是重要的预后不良因素.结论 S-ALCL患者发病年龄较轻,预后较好.但ALK-、LDH升高者预后不良.治疗以联合化疗为主,对于有不良预后因素的患者,大剂量治疗可能获益.     

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.     

非霍奇金淋巴瘤患者血清胆碱酯酶、乳酸脱氢酶及β2-微球蛋白的检测及其意义

目的 探讨非霍奇金淋巴瘤(NHL)患者血清胆碱酯酶(CHE)表达水平与患者临床特征及血清乳酸脱氢酶(LDH)、β2-微球蛋白(β2-MG)表达的相关性.方法 分别采用速率法、免疫法检测74例NHL患者血清CHE、LDH、β2-MG值,根据血清CHE均值5750 U/L分成低CHE水平组38例与高CHE水平组36例,比较两组患者的临床特征及LDH、β2-MG水平.结果 低CHE水平组与高CHE水平组血清CHE、LDH、β2-MG表达水平差异有统计学意义[(3714.2±1207.1)U/L、(435.7±36.4.4)U/L、(4.3±2.9)mg/L;(7898.2±1550.5)U/L、(247.4±134.8)U/L、(2.7±1.2)mg/L](t=10.510,P=0.000;t=2.969,P=0.005;t=3.043,P=0.004);两组年龄、病理类型、WBC、Plt差异无统计学意义(t=0.166,P=0.868;x2=0.751,P=0.386;t=1.626,P=0.111;t=1.987,P=0.056);两组性别、Ann Arbor分期有明显不同,低CHE水平组以男性(x2=5.432,P=0.020)、Ann Arbor Ⅲ～Ⅳ期(x2=9.394,P=0.024)患者为主.低CHE水平组血红蛋白含量[(97.6±25.8)g/L胝于高CHE水平组[(113.4±15.2)g/L],差异有统计学意义(t=3.230,P=0.002).结论 NHL患者CHE低活性与年龄、病理类型、WBC、Plt无关,与男性、Ann ArborⅢ/Ⅳ期、贫血、LDH、β2-MG高表达相关.     

MUM1/IRF4在滤泡性淋巴瘤中的表达及其临床病理意义

目的 探讨MUM1/IRF4在滤泡性淋巴瘤(FL)中的表达情况及临床病理意义.方法 对96例FL患者标本进行MUM1、CD10、bcl-2、bcl-6、Ki-67免疫组织化学染色,并与患者的临床资料和病理学特征比较.结果 MUM1在96例FL中总的阳性率为59.2%(58/96),其中1～2级组阳性率为36.2%(19/51),3级组阳性率为86.4%(39/45)(x2=24.406,P<0.001).68.9%伴有弥漫成分的FL患者MUM1阳性(x2=8.161,P=0.004).MUM1和CD10的表达呈负相关,83.3%的CD10阴性病例表达MUM1(x1=12.649,P<0.001).MUM1阳性者核分裂和Ki-67标记指数高于MUM1阴性者(t=-3.852、t=-4.610,P<0.001).结论 MUM1可作为FL分型的标志物.MUM1阳性的FL可能为类似非生发中心B细胞分化特征的高度恶性淋巴瘤.     

PTEN、MLL基因在T淋巴母细胞淋巴瘤/白血病的表达及其意义

目的 分析肿瘤抑制基因PTEN、混合系白血病(MLL)基因等在T淋巴母细胞淋巴瘤/白血病(T-LBL/ALL)的表达及意义.方法 选用76例T-LBL/ALl患者淋巴结存档蜡块,应用免疫组织化学EnVision法进行 PTEN标记,用20例反应性增生淋巴结标本作正常对照.并用荧光原位杂交(FISH)技术检测MLL基因所在1 1q23染色体的断裂和扩增情况.结果 76例T-LBL/ALL中,PTEN的表达率为64.47%(49/76),低于淋巴结反应性增生的100%(20/20)(λ2=19.220,P＜0.05).PTEN表达与临床分期、Ki-67、乳酸脱氢酶(LDH)呈负相关(P＜0.05).76例T-LBL/ALL中,MLL基因发生1 1q23染色体断裂13例(17.11%),扩增18例(23.68%).MLL基因断裂组总体生存率(25.0%)低于非断裂组(43.6%)(λ2=11.357,P＜0.05).MLL基因扩增组总体生存率(17.1%)低于非扩增组(42.7%)(λ2=4.533,P＜0.05).结论 抑癌基因PTEN表达降低在T-LBL/ALL的发生发展中可能具有重要作用.MLL基因发生染色体1 1q23断裂和扩增有助于对T-LBL/ALL预后的判断,发生MLL基因断裂或扩增的T-LBL/ALL预后较差,提示MLL基因断裂或扩增可能为T-LBL/ALL的一种分子亚型.     

艾滋病病毒感染合并口腔浆母细胞型淋巴瘤一例临床病理分析

目的 分析艾滋病病毒(HIV)合并口腔浆母细胞型淋巴瘤的形态学特点、免疫表型及鉴别诊断.方法 对1例HIV合并口腔浆母细胞型淋巴瘤进行形态学、免疫组织化学分析及文献复习.结果 免疫组织化学显示CD-20、CD-3、CD-45、CD-30、ALK(-)、EBV(+)、CD138灶(+)、Ki-67 90%(+)、EMA灶(+)、CD68组织细胞(+)、CDRB灶(+)、CD45RO个别(+)、CD-79a、CD-56、IgM、IgG、IgA、HMB45、bcl-2、CD5、cyclinD1、CD43、CD10、Desmin、MPO、CD15、MYOD1、CK均为(-).病理诊断弥漫大B细胞淋巴瘤浆母细胞型分化.结论 弥漫性大B细胞淋巴瘤病理类型多样,HIV合并口腔浆母细胞型较少见,掌握其形态学特征,熟悉各类型的免疫表型的异同点对诊断与鉴别诊断有重要意义.     

鼻型自然杀伤-T细胞淋巴瘤31例临床分析

目的 分析结外鼻型自然杀伤(NK)-T细胞淋巴瘤的临床特点及治疗方案,提高对鼻型NK-T细胞淋巴瘤的认识.方法 对经病理证实的鼻型NK-T细胞淋巴瘤31例的临床资料进行回顾性的分析结果31例患者中,EB病毒(EBV)感染24例(77.42%).近期疗效结果显示,放疗、化疗、放疗+化疗差异无统计学意义(x2=3.61,P＞0.05).随访截至2010年10月,3l例患者中死亡24例,7例生存,其中4例无瘤生存.19例死于肿瘤复发或进展.全组中位生存时间为32个月.患者5年生存情况与临床分期、区域淋巴结受累、B症状、乳酸脱氢酶(LDH)水平、局部肿瘤浸润、EBV感染、早期治疗有 关(x2值分别为8.88、7.25、16.95、6.00、7.23、7.44、7.80,均P＜0.05).结论 放疗、化疗、放疗+化疗治疗鼻型NK-T细胞淋巴瘤疗效差异不大;患者的生存情况与临床分期、区域淋巴结受累、B症状、LDH水平、局部肿瘤浸润、EBV感染、早期治疗等临床特征有关.     

P53突变蛋白表达对弥漫大B细胞淋巴瘤预后的预测作用

目的 探讨p53突变蛋白表达对弥漫大B细胞淋巴瘤(DLBCL)预后的预测作用,指导个体化治疗.方法 随机选择初治DLBCL患者62例,应用免疫组织化学方法检测p53突变蛋白和CD10、bcl_6、MUM1的表达,分析p53突变蛋白表达与患者临床特征、分子分型以及预后的关系.结果 48.4%(30/62)的患者表达p53突变蛋白.p53突变蛋白表达与初始治疗反应有关(x2=20.365,P=0.040),阳性组的完全缓解率为33.3%(10/30),阴性组为59.4%(19/21);与分子分型有关(x2=31.023,P=0.021),阳性组非生发中心型比例显著高于阴性组,分别为83.3%和56.2%;与其他临床特征无关.多因素生存分析显示p53突变蛋白表达是独立的预后预测因子,阳性组的无进展生存期和中位生存期均短于阴性组(x2=36.784,P=0.005和x2=35.276,P=0.006).结论 p53突变蛋白表达是DLBCL独立的不良预后因子,能够用来指导个体化治疗.     

儿童侵袭性成熟B细胞淋巴瘤的临床病理学及分子遗传学特点

目的 分析总结中国儿童各类型侵袭性成熟B细胞淋巴瘤的临床病理学及分子遗传学特点,为其诊断的标准化提供依据.方法 收集97例儿童侵袭性成熟B细胞淋巴瘤石蜡包埋组织标本,包括伯基特淋巴瘤(BL)81例、弥漫大B细胞淋巴瘤(DLBCL)8例、介于BL和DLBCL间的不能分类的B细胞淋巴瘤(BL/DLBCL)8例,利用免疫组织化学技术和间期荧光原位杂交(FISH)技术检测其免疫表型和分子遗传学特征.结果 BL的bcl-2和MUM1的阳性率分别为3%(2/66)和17%(12/71),DLBCL分别为50%(4/8)和63%(5/8),BL/DLBCL分别为50%(4/8)和63%(5/8).BL、DLBCL和BL/DLBCL的Ki-67平均值分别为(93±4.4)%、(83±14.3)%和(80±11.5)%.BL、DLBCL和BL/DLBCL的c-myc基因易位的比例分别为98%(79/81)、38%(3/8)和50%(4/8).38%(3/8)的DLBCL和25%(2/8)的BL/DLBCL存在bcl-6基因的多拷贝,BL与DLBCL之间、BL与BL/DLBCL之间bcl-2、MUM1和Ki-67平均值的差异及c-myc基因易位和bcl-6基因多拷贝的差异均有统计学意义(均P＜0.05).结论 儿童侵袭性成熟B细胞淋巴瘤的诊断和分型需要综合分析形态学、免疫表型和分子遗传学特征.儿童BL/DLBCL可能是DLBCL的一个亚型.CD10+、bcl-6+、bcl-2-、Ki-67＞90%、伴有IGH/c-myc重排、不伴有bcl-2和bcl-6重排时,支持BL的诊断;bcl-2+、Ki-67为50%～90%,同时伴有bcl-6基因的多拷贝时,支持DLBCL或BL/DLBCL的诊断.     

NPM/ALK gene fusion transcripts identify a distinct subgroup of null type Ki-1 positive anaplastic large cell lymphomas

The chromosomal aberration t(2:5) resulting in the juxtaposition of NPM and ALK genes is a well-known feature of several Ki-1+ anaplastic large cell lymphomas (ALCL) of the T-cell type. However, conflicting results have been reported concerning the presence of this gene rearrangement in other ALCL and Hodgkin's disease (HD), respectively. We performed NPM/ALK RT-PCR on 14 cases of ALCL expressing distinct myelomonocytic markers, e.g. CD11c, CD13, CD14 or CD68, but neither T-cell nor B-cell associated antigens (null cell phenotype). The specific translocation was found exclusively in six childhood tumours previously diagnosed as malignant histiocytosis (MH), whereas all adult lymphomas (three ALCL without characteristics of MH, three secondary ALCL following HD) and two paediatric cases of secondary ALCL following HD did not show NPM/ALK gene fusion products. By Southern blotting, the status of T-cell receptor (TCR) and immunoglobulin heavy chain genes (IgH) were investigated; two patients with initially diagnosed MH had the TCRdelta-chain gene rearranged (Ddelta2-Ddelta3 and Vdelta1-Jdelta1, respectively). IgH rearrangements were detected in only one patient with secondary ALCL. Our data indicate a high association of previously diagnosed MH and NPM/ALK gene rearrangements. In one case, this specific translocation was demonstrated at an early stage of development; in another, a mature TCRdelta-chain gene rearrangement was detected. These data support the hypothesis of a lymphoid origin of this subgroup of Ki-1 positive ALCL previously diagnosed as MH.     

The cryptic inv(2)(p23q35) defines a new molecular genetic subtype of ALK-positive anaplastic large-cell lymphoma

Recently, a distinctive entity characterized by expression of the anaplastic lymphoma kinase (ALK) protein [most frequently due to the t(2;5)(p23;q35)-associated NPM-ALK fusion] has emerged within the heterogenous group of non-Hodgkin's lymphomas (NHL) classified as anaplastic large-cell lymphoma (ALCL). Sporadic variant 2p23/ALK abnormalities identified in ALK-positive ALCL indicate that genes other than NPM may also be involved in the deregulation of ALK and lymphomagenesis. We report here three cases with an inv(2)(p23q35) detected by fluorescence in situ hybridization (FISH) in young male patients with ALK-positive ALCL. In contrast to ALCL cases with the classical t(2;5)(p23;q35) that usually show both cytoplasmic and nuclear or predominantly nuclear alone localization of the NPM-ALK chimeric product, in all three cases with an inv(2)(p23q35) the ALK protein accumulated in the cytoplasm only, supporting the previous assumption that the oncogenic potential of ALK may not be dependent on its nuclear localization. As the first step to identify the ALK partner gene involved in the inv(2)(p23q35), we performed extensive FISH studies and demonstrated that the 2q35 breakpoint occurred within the 1,750-kb region contained within the 914E7 YAC. Moreover, a striking association of the inv(2)(p23q35) with a secondary chromosomal change, viz, ider(2)(q10)inv(2)(p23q35), carrying two additional copies of the putative ALK-related fusion gene, was found in all three patients, suggesting that, in contrast to the standard t(2;5)/NPM-ALK fusion, multiple copies of the putative 2q35-ALK chimeric gene may be required for efficient tumor development. In summary, we demonstrate that the inv(2)(p23q35), a variant of the t(2;5)(p23;q35), is a recurrent chromosomal abnormality in ALK-positive ALCL, the further characterization of which should provide new insight into the pathogenesis of these lymphomas.     

CD30(+) anaplastic large-cell lymphoma in children: analysis of 82 patients enrolled in two consecutive studies of the French Society of Pediatric Oncology

The purpose of this study was (1) to investigate the efficacy of chemotherapy regimens designed by the French Society of Pediatric Oncology for childhood anaplastic large-cell lymphoma (ALCL) and (2) to identify prognostic factors in these children. Eighty-two children with newly diagnosed ALCL were enrolled in two consecutive studies, HM89 and HM91. The diagnosis of ALCL was based on immuno-morphological features and all the cases but 2 were investigated using ALK1 antibody directed to the NPM/ALK protein associated with the 2;5 translocation. Treatment consisted of 2 courses of COPADM (methotrexate, cyclophosphamide, doxorubicin, vincristine, and prednisone) and a maintenance treatment of 5 to 7 months. Seventy-eight patients (95%) achieved a complete remission and 21 relapsed. The probability of survival and event-free survival at 3 years was of 83% (72% to 90%) and 66% (54% to 76%), respectively, with a median follow-up of 49 months. In multivariate analysis, visceral involvement, mediastinal involvement, and lacticodeshydrogenase (LDH) level >/=800 UI/L were shown to be predictive of a higher risk of failure. In conclusion, this type of regimen demonstrated efficacy in childhood ALCL. However, therapeutic results have to be improved for children with adverse prognostic parameters such as visceral or mediastinal involvement or a high LDH level.     

ALK expression defines a distinct group of T/null lymphomas ("ALK lymphomas") with a wide morphological spectrum

The t(2;5)(p23;q35) translocation associated with CD30-positive anaplastic large cell lymphoma results in the production of a NPM-ALK chimeric protein, consisting of the N-terminal portion of the NPM protein joined to the entire cytoplasmic domain of the neural receptor tyrosine kinase ALK. The ALK gene products were identified in paraffm sections by using a new anti-ALK (cytoplasmic portion) monoclonal antibody (ALKc) that tends to react more strongly than a previously described ALK1 antibody with the nuclei of ALK-expressing tumor cells after microwave heating in 1 mmol/L ethylenediaminetetraacetic acid buffer, pH 8.0. The ALKc monoclonal antibody reacted selectively with 60% of anaplastic large cell lymphoma cases (60 of 100), which occurred mainly in the first three decades of life and consistently displayed a T/null phenotype. This group of ALK-positive tumors showed a wide morphological spectrum including cases with features of anaplastic large cell lymphoma "common" type (75%), "lymphohistiocytic" (10%), "small cell" (8.3%), "giant cell" (3.3%), and "Hodgkin's like" (3.3%). CD30-positive large anaplastic cells expressing the ALK protein both in the cytoplasm and nucleus represented the dominant tumor population in the common, Hodgkin's-like and giant cell types, but they were present at a smaller percentage (often with a perivascular distribution) also in cases with lymphohistiocytic and small cell features. In this study, the ALKc antibody also allowed us to identify small neoplastic cells (usually CD30 negative) with nucleus-restricted ALK positivity that were, by definition, more evident in the small cell variant but were also found in cases with lymphohistiocytic, common, and "Hodgkin's-like" features. These findings, which have not been previously emphasized, strongly suggest that the neoplastic lesion (the NPM-ALK gene) must be present both in the large anaplastic and small tumor cells, and that ALK-positive lymphomas lie on a spectrum, their position being defined by the ratio of small to large neoplastic cells. Notably, about 15% of all ALK-positive lymphomas (usually of the common or giant cell variant) showed a cytoplasm-restricted ALK positivity, which suggests that the ALK gene may have fused with a partner(s) other than NPM. From a diagnostic point of view, detection of the ALK protein was useful in distinguishing anaplastic large cell lymphoma cases of lymphohistiocytic and small cell variants from reactive conditions and other peripheral T-cell lymphoma subtypes, as well as for detecting a small number of tumor cells in lymphohemopoietic tissues. In conclusion, ALK positivity appears to define a clinicopathological entity with a T/null phenotype ("ALK lymphomas"), but one that shows a wider spectrum of morphological patterns than has been appreciated in the past.     

Detection of the t(2;5)-associated NPM/ALK fusion cDNA in peripheral blood cells of healthy individuals

The translocation t(2;5), which leads to the fusion of the nucleophosmin gene (NPM) on chromosome 5q35 to the receptor kinase ALK on chromosome 2p23, is found in CD30+ anaplastic large cell lymphomas and some cases of B-cell lymphoma. Hodgkin's disease (HD) is a malignant lymphoma characterized by large multinucleated tumour cells, Hodgkin and Reed-Sternberg (H&RS) cells, surrounded by a dense lymphohistiocytic infiltrate. Our group recently demonstrated NPM/ALK fusion cDNAs by single-cell RT-PCR in < 3% of CD30+ tumour cells in 2/9 cases of HD. To further delineate the relevance of this finding for HD, we studied the occurrence of NPM/ALK fusion genes in peripheral blood cells of healthy donors by RT-PCR. NPM/ALK fusion cDNAs were found by RT-PCR in 14/29 healthy individuals and confirmed by hybridization with a breakpoint-specific oligonucleotide. Due to the low rate of NPM/ALK-positive cells in the peripheral blood of positive individuals, an assignment to a defined cellular subpopulation was not possible. We conclude that NPM/ALK fusion genes are present in peripheral blood cells of healthy donors. After t(14;18) and t(9;22), t(2;5) represents the third example of tumour-associated translocation products in blood cells of apparently healthy donors. The implications of this finding are discussed.