Adult T-cell Leukemia Virus (ATLV)-associated Lymphoma

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Acta Med. Nagasaki 31 : 314-321

Junji IRE, Kenji MATSUO, Kazumasa FUKUDA, Hideo TSUCHIYAMA and Shimeru KAMIHIRA*

Department of Pathology, Nagasaki University School of Med icine

* Division of Medicine, Nagasaki Citizens' Hospital

Received for publication, July 11, 1986

SUMMARY

An autopsy case of malignant lymphoma presenting T-cell phenotype in life and B -cell phenotype at autopsy is reported . The histology of a biopsy of right cervical lymph nodes in a 56-year-old woman revealed "non-Hodgkin's lymphoma, diffuse, medium-sized cell type". 74.5% of lymphoid cell suspensions formed the spontaneous rosettes with sheep erythrocytes.

Proviral DNA of adult T-cell leukemia virus was found after cell fraction. She was treated as adult T-cell leukemia. On the 69th hospital day, however, she died and autopsy was performed. The histology of lymph nodes of the neck at autopsy showed a diffuse proliferation of small to medium-sized neoplastic cells with the interspersed immunoblasts.

Electron microscopically, these proliferating neoplastic cells differentiated into the immunoblasts to plasma cells. Also, they showed positivity for the PAP immunostaining method with anti-IgA and x sera.

INTRODUCTION

Adult T-cell leukemia (ATL) was described by Takatsuki and his coworker.12)14)16) Many studies have been reported in ATL.1)3)4)6)9) The clinical and hematological characteristics are i ) onset in adulthood ii) acute or chronic leukemia with rapid progression iii) resistance to treatment with current antileukemic agents iv) appearance of pleomorphic leukemic cells with a markedly deformed nuclei v) frequent accompaniment by

入江準二,松尾健治,福田一正,土山秀夫,上平憲 314

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lymphadenopathy, hepatosplenomegaly, and hypercalcemia vi) absence of mediastinal tumor, and vii) these patients had been born in and around Kyushu region in Japan.

Recently human retrovirus adult T‑cell leukemia virus (ATLV) has been shown to be closely associated with ATL.2)7)8)15) YAMAMOTO et al. stated that ATLV infected not only T but also B, non‑T and non‑B cells.13)

We described a rare case of ATL presenting neoplastic B‑cell phenotype at autopsy.

CASE REPORT

A 56‑year‑old woman complained of common cold‑like symptoms at the beginning of February, 1983. Since she noticed painful lymphadenopathy at neck, she visited Nagasaki Citizens' Hospital on February 23, 1983.

On admission, generalized lymphadenopathy and skin eruption of the trunk were present. Hepatosplenomegaly was not recognized. Laboratory studies showed the fol‑

lowings : red blood cell count 354xlO"/cmm, white blood cell count 4900lcmm with a differential of 63% segmented neutrophils, 8% bands, 6% eosinophils, 7% monocytes, 21%

lymphocytes and no abnormal cells.

On March 2, 1983, a biopsy of right cervical lymph nodes was carried out. The histology revealed "non‑Hodgkins lymphoma, diffuse, medium‑sized cell type". 74.5% of lyrnphoid cell suspensions formed the spontaneous rosettes with sheep erythrocytes. They showed positivity for Leu‑1 monoclonal antibody. The provirus of ATL was found in DNA of lymphoid cell suspensions. Therefore she was diaguosed as ATL.

On March 15, a combination chemotherapy with vincristine, endoxan, predonisolone and adriamycin was begun. Her lymphadenopathy gradually reduced, but this chemother‑

apy paused for a time owing to its side effect.

At the middle decade of May, her chest X‑ray showed fine nodular densities scattered throughout lung fields. The blood gases showed impaired diffusion with severe hypoxemia. She was treated with cotrimoxazole and oxygen inhalation. Dyspnea, however, persisted and she became cyanotic. She died on June 3, 1983 and autopsy was perf ormed.

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316 J. IRIE ET AL

MATERIALS AND METHODS

Cell markers and analysis of proviral DNA of ATLV

Cell suspensions were prepared from fresh right cervical lymph node biopsy by mincing and filtering the tissue through gauze. The cell suspension was centrifuged through a Ficoll‑Conray gradient to obtain viable mononuclear cells. The mononuclear cells at the interphase were collected, washed three times with phosphate‑buffered saline (PBS), and examined for viability by the exclusion of trypan blue. Free cells were tested for spontaneous rosettes with neuraminidase treated sheep erythrocytes (SRBO (JIMRO Co.. Ltd.). Moreover, SRBC‑rosette forming lymphoid cells were examined for reactivity with monoclonal antibodies to T‑cells (Leu‑1, Leu‑2a and Leu‑3a). DNA was extracted from cell suspension and analyzed to detect the integrated proviral DNA.

Light microscopy

Materials were obtained from the right cervical lymph node biopsy and lymph nodes of the neck at autopsy. The tissues were fixed in 10% neutral formalin, and hematoxylin

‑eosin (H. E.), periodic acid‑Schiff (PAS), silver impregnation and methyl green pyronin were performed.

For light microscopic detection of cytoplasmic immunoglobulins (Ig), immunoperox‑

idase method (PAP method) was carried out employing anti‑Ig, x and sera (DAKO).

Electron microscopy

The formalin‑fixed lymph nodes at autopsy were cut ir)to small piece of blocks, fixed for 2 hours in Karnovsky's solution at 4'C and postf,ixed in 1% osmium tetroxide.

They were dehydrated in graded ethanol series and embedded in Quetol 812.

RESULTS

Cell markers and analysis of proviral DNA of ATL V

SRBC‑rosette forming cells were 74.5% of lymphoid cells in suspensions prepared frorn fresh right cervical lymph node biopsy, and positive for Leu‑1 monoclonal antibody and negative for Leu‑2a and Leu‑3a monoclonal antibodies. Proviral DNAof ATLV was found in cell fraction. But no examination of cell marker and analysis of proviral DNA of ATLV were performed before death.

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ATLV‑ASSOCIATED LYMPHOMA ³¹⁷

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318 J. IRIE ET AL

diagnosis was "non‑Hodgkin's lymphoma, diffuse, medium‑sized cell type", according to LSGJ classification. All of proliferationg cells were negative for anti lg, and sera.

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The immunoblasts had hyperchromatic, Iarge nucleus with distinct uncleolus and slightly basophilic cytoplasm which showed strong pyroninophilia. The neoplastic cells were partially positive for anti lgA and x sera employing the PAP immunostaining method (Fig.

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Electron microscopy

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320 J. IRIE ET AL

DISCUSSION

Adult T‑cell leukemia have been found in Japan. This disease revealed clinically and hematologically several characteristics.

In 1981, HINUMA et al.2) detected ATL‑associated antigen on MT‑1, which originated from patients with ATL,5) by indirect immunofluorescence. Also they observed type C virus particle on MT‑1 cells. The provirus genome was detected in the chromosomal DNA of ATL.7)8) 5) It has been interpreted that ATL is related with retrovirus. In this case, also, proviral DNA of ATLV was found in cell fraction of right cervical lymph nodes.

Therefore, the present case wzis confirmed in life.

Cell suspensions from patients with ATL form spontaneous rosettes with sheep erythrocytes and are frequently positive for Leu‑1, Leu‑3a and Leu‑4 monoclonal antibodiesl2). In our case, however, SRBC‑rosette forming cells were positive for Leu‑l and negative for Leu‑3a monoclonal antibody, which was atypical reaction as ATL.

It is generally agreed that neoplastic cells of ATL are peripheral T‑cells.3) ATL has never been reported to be associated with a proliferation of B‑cell phenotype cells. In this case, the histology of lymph nodes of the neck at autopsy showed diffuse proliferation of immunoblasts to plasma cells. It was determined electron microscopically and im‑

munohistochemically that the neoplastic cells were B‑cell phenotype. YAMAMOTO et al.13) reported that B‑cells acted as reservoir in infected individuals. Consequently no examina‑

tion of cell markers and chromosomal anomaly were carried out in our case before death, but it is considered that B‑lymphocytes became infected with ATLV, and ATLV‑infected B‑1ymphocytes became neoplastic and proliferated.

Although proviral DNA of ATLV was found, the present case differs from ATL in point of reactivity with monoclonal antibodies to T‑cells (Leu‑1, Leu‑2a and Leu‑3a) and a proliferation of B‑cell phenotype at autopsy. Therefore, our case prefers to be called ATLV‑associated lymphorna rather than ATL.

Acknowledgement : We wish to thank Dr. Mitsuaki Yoshida, Department of Oncology, Cancer Institute for analysis of proviral DNA of ATLV.

REFERENCES

1 ) HANAOKA M SASAKI M MATSUMOTO, H., TANKAWA, H., YAMABE, H., TOMIMOTO K

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TASAKA, C., FUJIWARA, H., UcHIYAMA, T. and TAKATSUKI, K. : Adult T cell leukemia.

Histological classification and characteristics. Acta Pathol. Jpn. 29 : 723‑738, 1978.

2 ) HINUMA, Y., NAGATA, K., HANAOKA, M., NAKAI, M., MATSUMOTO, T., KINOSHITA, K., SHIRAKAWA, S. and MrvosHL I. : Adult T‑cell leukemia. Antigen in an ATL cell line and detection of antibodies to the antigen in human sera. Proc. Natl. Acad. Sci. U. S.

A. 78 : 6476‑6480, 1981.

3 ) KlNOSHITA, K., KAMIHIRA, S., IKEDA, S., YAMADA, Y., MuTA, T., KITAMURA,

T., ICHIMARU, M. and MATSUO, T. : Clinical, hematologic, and patholqgic features of leukemic T‑cell leukemia. Cancer 50 : 1554‑1562, 1982.

4 ) MrrsUl, T., KIKUCHI, M., EIMoTO, T., NISHlUCHI, M. and TOYOOKA, R. : Non‑Hodgkin's lymphoma in northwestern Kyushu Island of Japan. Acta Pathol. Jpn. 33 : 71‑88, 1983.

5 ) Mrvosm, I., KUBONISHI, I., SUMIDA, M., YOSHIMOTO, S., HIRAKI, S., TSUBOTA,

T., KOBASHI, H., LAL M., TANAKA, T., KIMURA, I., MIYAMOTO, K. and SATo, J. : Character‑

istics of a leukemic T‑cell line derived from adult T‑cell leukemia. Jpn. J. Clin. Oncol.

9 : 485‑494, 1979.

6 ) Mrvosrn, I., KUBONISHI, I., SUMIDA, M., HIRAKI, S., TSUBOTA, T., KIMURA, I., MIYAMOTO, K.

and SATo, J. : A novel T‑cell line derived from adult T‑cell leukemia. Gann 71 : 155

‑156, 1980.

7 ) SEIKI, M., HATTORI, S. and YOSHIDA, M. : Human adult T‑cell leukemia virus.

Molecular cloning of the provirus DNA and the unique terminal structure. Proc. Natl.

Acad. Sci. U. S. A. 79 : 6899‑6902, 1982.

8 ) SEIKL M., HATTORI, S., HIRAYAMA, Y. and YOSHIDA, M. : Human adult T‑cell leukemia virus. Complete nucleotide sequence of the provirus genome integrated in leukemia cell DNA. Proc. Natl. Acad. Sci. U. S. A. 80 : 3618‑3622, 1983.

9 ) SHIMIZU, M., MlURA, M., KITAHARA, M. and KATAYARA, I. : Non‑Hodgkin's lymphomas analysis of 109 Japanese cases with the use of LSGJ classfication. Am. J. Pathol. 106 : 30‑39, 1982.

10) SUCm, T.. TAJIMA, K., NANBA, K., WAKASA, H., MIKATA, A., KIKUCHI, M., MoRI, S., WATANABE. S., MoHRI, N., SHAMOTO, M., HARIGAYA, K., ITAGAI, T., MATSUDA, M., KIRINo, Y., TAKAGI, K. and FUKUNAGA, S. : Some problems on the histopathological diagnosis of non‑Hodgkin's lymphoma. A proposal of a new type. Acta pathol. Jpn. 29: 755‑776, 1979.

11) TAKATSUKI. K., UcHIYAMA, T., SAGAWA, K. and YoDol, J. : Adult T‑cell leukemia in Japan. Topics in Hematology, eds. SENo, S., TAKAKU, F. and IRINO, S. pp 73‑77, Excerpta Medica. Amsterdam, 1977.

12) YAMAMOTO. N. : Adult T‑cell leukemia and ATL virus. Igakuno ayumi 1 26 : 655‑662, 1983. (in Japanese)

13) YAMAMOTO, N., MATSUMOTO, T., KOYANAGI, Y., TANAKA, Y. and HlNUMA, Y. : Unique cell lines harbouring both Epstein‑Barr virus and adlut T‑cell leukemia virus, established from leukemia patients. Nature 299 : 367‑369, 1982.

14) YoDOI, J.. TAKATSUKI, K. and MATSUDA, T. : Two cases of T‑cell chronic lymphocytic leukemia in Japan. New Engl. J. Med. 290 : 572‑573, 1974.

15) YOSHIDA, M. : Human leukemia virus associated with adult T‑cell leukemia. Gann 74 : 777‑789, 1983.

16) UcHIYAMA, Y., YoDoL J., SAGAWA, K., TAKATSUKI, K. and UcmNo, H. : Adult T‑cell leukemia. Clinical and hematologic features of 16 cases. Blood 50 : 481‑492, 1977.