Adult T-cell Leukemia/lymphoma Cases Research Articles

Trends in HTLV‐1 prevalence and incidence of adult T‐cell leukemia/lymphoma in Nagasaki, Japan

Most previous studies aimed at estimating the number of human T-cell leukemia virus type-1 (HTLV-1) carriers in endemic areas have been based on seroprevalence rates in blood donors; however, this may result in underestimation because of the healthy donor effect. People who have health problem do not donate blood. In the present study, the number of HTLV-1 carriers in Nagasaki City was estimated based on the seroprevalence rates in a hospital-based population from Nagasaki University Hospital. In accordance with previous reports, seroprevalence of HTLV-1 was higher in females, and year of birth-specific seroprevalence showed a significant annual decline in both genders (P for trend: <0.0001). The estimated number of HTLV-1 carriers in Nagasaki City was 36,983. The incidence of adult T-cell leukemia/lymphoma (ATLL) among HTLV-1 carriers was estimated using data from the Nagasaki Prefectural Cancer Registry. The estimated annual incidence of ATLL was 61 per 100,000 HTLV-1 carriers, and the crude lifetime risk of the development was 7.29% for males and 3.78% for females. There is a large pool of HTLV-1 carriers aged over 70 years, and a continuing development of cases of ATLL among the elderly is therefore expected.

Immunophenotyping of mature T/NK cell neoplasm presenting as leukemia

Mature T/NK cell lymphomas (MTNKL) presenting as leukemia are rare and show considerable overlapping of clinical, morphological and immunophenotypic features. Critical analysis of the morphology and immunophenotypic profile of MTNKL. We reviewed 380 consecutive cases of mature lymphoid neoplasm that presented as leukemia and were diagnosed on morphology and immunophenotyping of bone marrow and/or peripheral blood samples. Peripheral blood and bone marrow involvement was seen in all cases. MTNKL constituted 4% (nine cases) of all mature lymphoid neoplasms presenting as leukemia. It included four cases of T-large granular leukemia (T-LGL), two of T-cell prolymphocytic leukemia small cell variant (T-PLL), two of adult T-cell leukemia/lymphoma (ATLL) and one of primary cutaneous gamma delta T-cell lymphoma (PCGDTCL). T-LGL revealed CD4-/CD8+ phenotype in three, and CD4+/CD8+ phenotype in one case. CD56 was absent in all the cases of T-LGL. One case of T- PLL small cell variant showed CD4+/CD8- phenotype, while the other revealed CD4-/CD8+ phenotype. Both cases of ATLL showed CD4+/CD8+/CD25+ phenotype. The single case of PCGDTCL showed CD4-/CD8- phenotype pattern. CD3 and CD5 were expressed in all MTNKL. CD7 was absent in three cases of T-LGL. TCRalpha/beta was performed in three cases of T-LGL and was positive in all. TCRalpha/beta was also seen in both the cases of T-PLL small variant. However, TCRalpha/beta was seen in the single case of PCGDTCL. Mature nodal T/NK cell neoplasms are rare and MTNKL presenting as leukemia are even rarer. There is an overlap between the immunophenotypic profiles of different MTNKL subtypes and elaborate T/NK cell panels are required for their evaluation.

Is Human T Cell Lymphotropic Type 1 (HTLV-1)-Associated Myelopathy/Tropical Spastic Paraparesis (HAM/TSP) Syndrome a Neglected Disease?

Human T cell lymphotropic type 1 (HTLV-1) was the first human retrovirus discovered and has been associated mainly with two illnesses [1], an inflammatory disease named HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP), and a neoplastic condition called adult T cell leukemia/lymphoma (ATL) [2]. Although this virus has worldwide distribution, Japan, Africa, the Caribbean basin, and South America are considered to be endemic areas [3]. It has been estimated that 10–20 million people are infected with this virus [4], but the majority are asymptomatic and probably not aware of their serological status. There is no accurate number of HAM/TSP or ATL cases since these diseases are not considered reportable by the World Health Organization (WHO), although Japan reports approximately 800 cases of ATL yearly [5]. In 1985, Roman et al. used the term tropical spastic paraparesis (TSP) for the first time, modifying the term “tropical spastic paraplegia” as used in South India in 1969, because only a few cases were completely paraplegic [6]. In the same year, it was found that almost 60% of patients with TSP were also positive for HTLV-1 compared with 4% of the controls, which suggested, for the first time, the neurotropism of human retroviruses [7]. In 1986, Osame et al. coined the term HTLV-1-associated myelopathy (HAM) [8]. In 1988, the WHO recommended “that the disease be known by the acronym HAM/TSP for the time being.” Thus, it seems that in endemic areas, about 60% of tropical spastic paraparesis cases are identified as HAM/TSP [7]. The rest are myelopathies probably caused by nutrition problems, intoxication, and unknown causes [6],[9]. HAM/TSP has an estimated incidence ranging from 0.25% to 1% after 30–40 years of incubation [9]. The onset of disease is 40 years of age, with predominance in women [10]. Several factors have been ascribed as potentials for clinical outcome, such as high HTLV-1 proviral load, genetic background, routes of transmission (i.e., breastfeeding or transfusion), and high antibody titers [11]. Despite the publication of several reviews regarding the pathogenesis or molecular biology of HTLV-1 [12],[13], few studies have addressed treatment for the diseases caused by this virus. Thus, this article will focus on the reason why HAM/TSP should be considered a neglected tropical disease. To illustrate our viewpoint, we present one case of HAM/TSP in which several important issues are raised as singularities of the problem. A 29-year-old black woman born in Bahia in northeast Brazil has been living in Sao Paulo city for several years. When she was 20, she began complaining of lumbar pain and parestesis, initially in one leg and then in both, in addition to miccional urgency and constipation. After 3 years of illness and several visits to doctors, including basic and intermediate complexity level services, she was referred to our service as a suspected case of HTLV-1 disease. The diagnosis of HAM/TSP was confirmed. The patient was using a wheelchair most of the time. Pulse therapy with methylprednisolone was administered three to four times per year, with programmed hospitalization for at least 5 days. Her husband abandoned her, and she lives with her two children in a small one-bedroom house in an area difficult to reach by car. Her only income is the government minimum wage (US$250.00/month), and she is unable to attend a facility for physical therapy. She depends on her friends or relatives to bring her to the clinic appointments.

Adult T‐cell leukemia/lymphoma in the Middle East: first report of two cases from Lebanon

Adult T-cell leukemia/lymphoma (ATL) is an aggressive lymphoproliferative disorder caused by human T-cell leukemia virus type I (HTLV-I). HTLV-I is endemic in southern Japan, the Caribbean, Central and South America, certain areas of Africa, and the southeastern United States. In the Middle East, North East Iran, particularly the region of Mashhad, has been recognized as an endemic region. In this report, the first two cases of ATL diagnosed in Lebanon are described. The first patient of Lebanese origin presented with acute ATL. The second patient of Romanian origin developed acute ATL in early relapse after autologous transplantation for ATL. Both patients had lymphocytosis, severe hypercalcemia, and CD25+ T-cell immunophenotype on peripheral blood. In both patients, HTLV-I serology was positive by enzyme-linked immunosorbent assay and confirmed by Western blot and HTLV-I oncoprotein Tax expression was documented in the leukemic cells. Upon screening, seven direct family members of the first patient were HTLV-I positive; four of them were regular blood donors. Screening blood donors for HTLV-I seropositivity is not currently performed in Lebanon. A large screening study in Lebanon is needed to confirm whether South Lebanon is a new endemic region for HTLV-I infection and to recommend mandatory screening of blood donors for HTLV-I infection.

Trends of incidence rate of adult T‐cell leukemia/lymphoma in an HTLV‐1 endemic area in Japan

Trends of incidence rate of adult T‐cell leukemia/lymphoma in an HTLV‐1 endemic area in Japan

Adult T-cell leukemia/lymphoma (ATL) presenting in the skin: Clinical, histological and immunohistochemical features of 52 cases

Background. Adult T-cell leukemia/lymphoma (ATL) is a severe disease caused by HTLV-I. This paper describes the clinicopathological and immunohistochemical findings of 52 cases of ATL with skin involvement and investigates whether there is any relationship between median survival time (MST) and histological patterns, primary cutaneous involvement and CD8 positivity.Material and methods. All cases were HTLV-I+ and HIV- and were clinically classified. HTLV-I proviral integration was investigated in atypical cases. Immunohistochemistry was performed using CD3, CD4, CD5, CD7, CD8, CD20, CD25, CD30 and CD45RO markers. Ki-67 was used to evaluate the proliferative index. Results. Twenty-seven cases were primary, while 25 were secondary. Monoclonal viral integration was demonstrated in all atypical cases. Patterns resembling mycosis fungoides (MF) were found in 19 cases and anaplastic large-cell lymphoma (ALCL) in two cases. Fifteen cases had an atypical immunophenotype and expressed CD8. Primary cutaneous ATL had a longer MST (48 months) than the secondary cutaneous ATL (7 months) and the difference was statistically significant, but no statistically significant difference was found between the MST of CD8-positive and negative cases.Conclusions. It is important to differentiate between primary and secondary cutaneous ATL and classify the cases histologically in order to better evaluate the prognosis. The two forms of primary cutaneous ATL, primary cutaneous smoldering and primary cutaneous tumoral (PCT), should also be identified. The smoldering type presented a longer survival (58 months) and histological aspects suggestive of better prognosis in contrast to the PCT type that had a shorter survival (20 months) and histological characteristics suggestive of worse outcome.

Leucemia/linfoma de células T do adulto

A leucemia/linfoma de células T do adulto (ATL) é tipo agressivo de doença linfoproliferativa causada pelo vírus linfotrópico para células T humanas (HTLV-I), geralmente fatal e que não responde a quimioterapia. Classifica-se em formas aguda, crônica, linfomatosa e indolente (smoldering). Outra forma clínica, a tumoral primária de pele, com características diferentes, foi sugerida recentemente. As formas aguda, linfomatosa e tumoral primária de pele são as de pior prognóstico. Os critérios diagnósticos de ATL são: sorologia positiva para o HTLV-I; diagnóstico citológico ou histológico de leucemia/linfoma de células T, CD4+/CD25+; presença de linfócitos T anormais em sangue periférico; confirmação de integração monoclonal do DNA proviral do HTLV-I. Há lesões de pele em cerca de 70% dos casos,que podem ser primários (formas indolente e tumoral primária da pele) ou secundários. As lesões cutâneas são múltiplas, sendo as mais freqüentes a eritrodermia, as pápulas e as placas. A ATL não tem aspecto histológico característico, podendo apresentar padrões superponíveis ao linfoma periférico T não especificado, à micose fungóide ou ao linfoma anaplásico de grandes células. O padrão imuno-histoquímico pode também simular o de outros tipos de linfoma T. Por esse motivo, é muito importante que no Brasil seja solicitada sorologia para o HTLV-I em todos os casos de leucemia e/ou linfoma de células T maduras.

Identification of Subtype-Specific Genomic Alterations of Acute and Lymphoma Types of Adult T-Cell Leukemia/Lymphoma.

Background: Adult T cell leukemia/lymphoma (ATLL) is a human T-lymphotropic virus type-I mediated neoplasm and four major clinical subtypes are recognized; i.e., smoldering, chronic, lymphoma and acute types. Among these subtypes, acute and lymphoma types are fetal disease with poor prognosis. Although these two subtypes represent different clinical features, detailed analysis for genomic/genetic differences has not been sufficiently investigated.Purpose: To investigate genomic aberrations of these subtypes, we performed array-based comparative genomic hybridization (array CGH: 2308 BAC clones spotted in duplicate) for 66 cases of ATLL (17 cases of acute and 49 cases of lymphoma subtypes). To determine target genes in recurrently amplified regions, quantitative real-time PCR (RQ-PCR) was conducted.Results: Array CGH: Comparison of genome profiles revealed that lymphoma type shows more frequent gain and loss than those of acute type. The numbers of respective genomic gain and loss regions of lymphoma type were 9.7 and 9.8 on average. The numbers of genomic gain and loss regions of acute type were 4.2 and 4.5 on average. Gain of 1q, 2p, 4q, 7p and 7q, and loss of 10p, 13q, 16q and 18p were characteristic to lymphoma type whereas gain of 3p and 3q was specific to acute type. Recurrent high-level amplifications were found at 1p35, 6p25, 7p22.2, 7q21–q22, 7q31–q36 and 14q32 in lymphoma type. However, such genomic amplifications were not found in acute type.RQ-PCR: CARMA1 (7p22 locus), which encodes signaling proteins associated with development of B and T cells, was a possible target of the 7p22 amplification in lymphoma type. The extremely higher expression of BCL11B (14q32 locus) which is a key regulator of both differentiation and survival during thymocyte development, was found in acute type irrespective of the 14q32 amplification. However, no overexpression of BCL11B was found in lymphoma type with high copy number gain, indicating that BCL11B is not the target gene for 14q32 amplification in the lymphoma type.Conclusion: Array-CGH revealed that patterns of genomic aberrations between acute and lymphoma types were different. Quantitative gene expression analysis also implicated distinct mechanism of aberrant gene expressions between acute and lymphoma types. Combination of array-CGH and quantitative gene expression analysis provided evidence that the acute and lymphoma types are developed via distinct genomic/genetic pathways.

FOXP3 Expression in B and T Cell Lymphomas.

Foxp3, which encodes a forkhead/winged helix transcription factor designated Scurfin, is a key regulatory gene required for the development and function of regulatory CD4+CD25+ T cells (Treg), a subpopulation of T-cells specialized in maintaining the balance between immunity and tolerance.Humans with defects in the FOXP3 gene, develop strong activation of the immune system, leading to multiorgan autoimmune disease, allergies, inflammatory bowel disease and severe infections, collectively known as the IPEX syndrome (immune deregulation, polyendocrinopathy, enteropathy, X-linked inheritance syndrome)Because of the importance of FOXP3 in the development and function of Treg cells, and its potential use as a specific Treg marker, we have developed several monoclonal antibodies against FOXP3, for use on paraffin-embedded tissue sections and evaluated its expression in a large series (150 cases) of B- and T-cell lymphomas. In reactive lymphoid tissue, strong nuclear FOXP3 expression was observed in approximately 5% of interfollicular T-cells. FOXP3 expression in tumour cells was confined to most of Adult T-cell Leukaemia/Lymphoma (ATLL) cases (68%), with some variability in protein expression. In other lymphoma types, FOXP3 expression was only detected in the reactive T-cell background, and the number of FOXP3-positive reactive T-cells was variable, ranging from almost a complete absence (Burkitt's lymphoma) to abundant infiltrate (common in follicular lymphoma).In conclusion, the availability of a FOXP3 monoclonal antibody, not only provides an important tool for the study of the development and function of Treg cells, but also represents a useful marker for the identification of ATLL cases in formalin-fixed paraffin-embedded tissue sections.The presence or absence of Treg cells in the tumour environment could also play a role in the immune surveillance of tumours, thus implying a potential additional value for the detection of this cell population in tumour samples.

Bone marrow transplantation from unrelated donors for patients with adult T-cell leukaemia/lymphoma

Adult T-cell leukaemia/lymphoma (ATLL) is a highly aggressive haematological malignancy. More than 40 cases of ATLL treated by allogeneic bone marrow transplantation (BMT) from sibling donors have been reported, while there have been only a few cases of unrelated BMT for treatment of this disease. We began performing allogeneic BMT from unrelated donors in 1999 to improve the outcome of ATLL patients with no suitable sibling donors. Eight ATLL patients underwent unrelated BMT; five received the conventional conditioning regimen consisting of cyclophosphamide and total body irradiation, while three received a reduced-intensity preparative regimen. Two patients died due to encephalopathy of unknown aetiology on days 10 and 35, and one patient died due to progression of ATLL 25 months after BMT. Five patients are currently alive and disease-free at a median of 20 months after BMT. Proviral human T-lymphotropic virus type-I (HTLV-I) DNA load in peripheral blood mononuclear cells (PBMCs) was assessed in four cases before and after BMT. HTLV-I proviral DNA load was reduced significantly after transplantation. Unrelated BMT is feasible for treatment of ATLL. Further studies in a larger number of cases are required to determine the optimal conditioning regimen and stem cell source.

Analysis of Interleukin-27 (EBI3/p28) Expression in Epstein-Barr Virus- and Human T-Cell Leukemia Virus Type 1-Associated Lymphomas: Heterogeneous Expression of EBI3 Subunit by Tumoral Cells

Interleukin (IL)-27 is a novel heterodimeric cytokine of the IL-12 family that is composed of two subunits, Epstein-Barr virus (EBV)-induced gene 3 (EBI3) and p28. EBI3 is expressed at high levels in EBV-transformed B-cell lines and is induced in vitro by the EBV oncogene LMP1 in a nuclear factor (NF)-kappaB-dependent manner. We show here that EBI3 expression is up-regulated in human T-cell leukemia virus type 1 (HTLV-1)-infected cell lines and IL-2-dependent leukemic cells from adult T-cell leukemia/lymphoma (ATL) patients, compared to normal activated T cells. EBI3 expression was decreased in HTLV-1-transformed cells after treatment with the NF-kappaB inhibitor BAY11-7082 and was induced in Jurkat cells by expression of HTLV-1 wild-type Tax oncoprotein, but not by the Tax mutant M22, which is defective for NF-kappaB activation. In situ analysis of EBI3 and p28 expression in Hodgkin's lymphomas (HLs), in various EBV-associated lymphoproliferative disorders (LPDs) (including post-transplant LPDs and nasal-type NK/T-cell lymphomas), and in ATL showed that EBI3 was expressed by neoplastic cells in all cases of HL and of LMP1-positive EBV-associated LPD, at variable levels in ATL cases, but rarely in control T-cell lymphomas. In contrast, in all lymphomas tested, no or few tumoral cells expressed p28. Consistent with these data, no significant p28 or IL-27 expression was detected in HL-derived cell lines, or in EBV- or HTLV-1-transformed cell lines. This selective overexpression of EBI3 by transformed cells suggests that EBI3 may play a role, independently from its association to p28, in regulating anti-viral or anti-tumoral immune responses.

FoxP3, a Key Molecule in CD4+CD25+ Regulatory T Cells, Express in Adult T Cell Leukemia/Lymphoma Cells and Relates to Clinicopathological Features.

AIMES: Adult T cell leukemia/lymphoma (ATLL) is an aggressive neoplastic disease and opportunistic infections often occur in patients with ATLL. However, the underlying mechanisms of such infections remain unknown. Recently, regulatory T cells (Treg), characterized by coexpression of CD4 and CD25, are proposed as a new T cell group with definite function. Treg suppresses normal T cells proliferation in vitro and play an important role to suppress autoimmune disease in vivo. But the deregulated proliferation such immunosuppressive T cells may induce immunodeficient status. We analyzed the expression of forkhead/winged helix transcription factor (FoxP3), known to be important for the function and specific marker of Treg cells, on ATLL cells.METHODS and RESULTS: FoxP3 expression was detected in both peripheral blood and lymph nodes in part of ATLL cases by real-time PCR and immunostaining (Figure). Next, we immunostained lymph node sections from 112 cases and 36 cases showed positivity for FoXP3. Morphologically, 112 ATLL cases were divided into three variants, namely pleomorphic cell type (61 cases), large cell type (45 cases), and anaplastic large cell type (16 cases). FoxP3 was expressed (more than 30% of the lymphoma cells) in a proportion of pleomorphic cell type (24 cases, 39.4%) and large cell type (12 cases, 26.7%) but no cases of anaplastic type showed positivity. Especially, strong expression (more than 50% of the lymphoma cells) was observed in 15 cases and 12 cases were pleomorphic cell type (Table). A proportion of FoxP3 positive ATLL cases showed intermingled EBV-infected transformed lymphocytes, suggesting local immunodeficient condition (Very few FoxP3 negative cases showed EBV-infected lymphocytes)(Table). Clinically, more proportion of FoxP3 positive ATLL cases showed opportunistic infection, for example Pneumocystis Carinii infections, Herpes zoster virus infection, antibiotics-refractory abscesses (Table).CONCLUSION: A proliferation of FoxP3 positive lymphoma cells may contribute to the tumor invasion and opportunistic infection by inducing local and diffuse immunodeficient status respectively. [Display omitted]

Expression of FoxP3, a key molecule in CD4CD25 regulatory T cells, in adult T-cell leukaemia/lymphoma cells.

Adult T-cell leukaemia/lymphoma (ATLL) is an aggressive neoplastic disease that usually exhibits a CD4(+)CD25(+) phenotype. Regulatory T cells (Treg), which suppress T-cell effector function, are characterized by the co-expression of CD4 and CD25. We analysed the expression of forkhead/winged helix transcription factor (FoxP3), a specific marker that is important for the function of Treg, on ATLL cells from 17 patients (peripheral blood, n = 8; lymph node, n = 9). Real-time polymerase chain reaction and immunostaining detected FoxP3 expression in 10 ATLL cases, but was relatively down-regulated compared with Treg from normal subjects. These results indicate the association of ATLL and Treg.

Rapid isolation of viral integration site reveals frequent integration of HTLV-1 into expressed loci.

Although there is tight association of the human T-cell leukemia virus type-1 (HTLV-1) with adult T-cell leukemia/lymphoma (ATLL), it has remained unresolved whether the HTLV-1 integration into the host genome has any role in the development of this disease. We isolated a total of 58 HTLV-1 integration sites using newly developed, adaptor-ligated PCR from 33 ATLL patients and five ATLL cell lines. We compared our data as well as the previously reported ones with the complete human genomic sequence for the location of its placement, structure, and expression of genes nearby the integration site. The chromosomal target for integration was selected at random, but the integration favorably occurred within the transcription units; more than 59.5% of total integration was observed within the transcriptional unit. All inserted genes by HTLV-1 integration were expressed in normal T cells. Upregulation of genes due to viral integration was found in two out of nine ATLL cases; about 4.4- and 102-fold elevated ankyrin-1 ( ANK-1) and gephyrin ( GPHN) gene expressions were observed, respectively. These data suggest that the preferential integration of HTLV-1 into an expressed locus occasionally causes deregulation of corresponding gene, which may lead to leukemogenesis of a fraction of ATLL.

An Immunohistochemical Analysis of Peripheral Blood Tissue Specimens from Leukemia Cells: Leukemic Cells of Adult T-cell Leukemia/Lymphoma Express p40Tax Protein of Human T-cell Lymphotropic Virus Type 1 When Entering Reproliferation

Human T-cell lymphotropic virus type 1 (HTLV-1) proviral DNA p40Tax (Tax) protein plays an important role in adult T-cell leukemia/lymphoma (ATLL) oncogenesis, but it has yet to be determined whether or not ATLL leukemic cells express Tax. In a study designed to answer this question, we prepared peripheral blood tissue specimens (PBTS) from four acute and seven chronic ATLL cases and three B-cell chronic lymphocyte leukemia (B-CLL) cases, and examined their immunological phenotype and Ki67 labeling index (Ki67LI) by means of antigen-retrieval immunohistochemistry. In three of the chronic ATLL cases, the difference in Ki67LI between leukemic cells that underwent either 3 hr, or more than 6 hr of sedimentation and coagulation while preparing PBTS suggested that the Ki67LI in PBTS represents reproliferating cells. Tax expression was examined by means of the ImmunoMax method. In two acute and three chronic type ATLL cases, leukemic cells expressed Tax in parallel with the Ki67LI, suggesting that Tax expression was related to reproliferation in PBTS. Leukemic cells in one case each of acute and chronic type ATLL did not express Tax. In one case of acute ATLL after chemotherapy, some cells expressed Tax among the other cells. These results indicate that ATLL leukemic cells are able to express an extremely small amount of Tax during reproliferation.

Role of tumor suppressor genes in the development of adult T cell leukemia/lymphoma (ATLL).

Adult T cell leukemia/lymphoma (ATLL) is one of the peripheral T cell malignant neoplasms strongly associated with human T cell leukemia virus type-I (HTLV-I). Although the viral transactivating protein Tax has been proposed to play a critical role in leukemogeneis as shown by its transforming activity in various experimental systems, additional cellular events are required for the development of ATLL. One of the genetic events in ATLL is inactivation of tumor suppressor genes. Among many candidates for tumor suppressor genes, the main genetic events have been reported to center around the cyclin-dependent kinase inhibitors ((CDKIs) p15INK4A, p16INK4B, p18INK4C, p19INK4D, p21WAF1, p27KIP1, and p57KIP2), p53 and Rb genes; all of them play a major regulatory role during G1 to S transition in the cell cycle. Acute/lymphomatous ATLL has frequent alterations of p15 (20%) and p16 (28-67%), while chronic/smoldering ATLL has fewer abnormalities of p15 (0-13%) and p16 (5-26%). Most of these changes are deletion of the genes; fewer samples have mutations. ATLL patients with deleted p15 and/or p16 genes have significantly shorter survival than those individuals with both genes preserved. Although genetic alterations of p18, p19, p21, p27 have rarely been reported, inactivation of these genes may contribute to the development of ATLL because low expression levels of these genes seem to mark ATLL. The p53 gene is mutated in 10-50% of acute/lymphomatous ATLL. Functional impairment of the p53 protein, even if the gene has wild-type sequences, has been suggested in HTLV-I infected cells. Each of these genetic events are mainly found in acute/lymphomatous ATLL, suggesting that alterations of these genes may be associated with transformation to an aggressive phenotype. The Rb tumor suppressor gene is infrequently structurally altered, but one half of ATLL cases have lost expression of this key protein. Notably, alterations of one of the CDKIs, p53 and Rb genes appear to obviate the need for inactivation of other genes in the same pathway. A novel tumor suppressor gene on chromosome 6q may also have a critical role in the pathogenesis of ATLL. Taken together, tumor suppressor genes are frequently altered in acute/lymphomatous ATLL and their alteration is probably the driving force fueling the transition from chronic/smoldering to acute/lymphomatous ATLL.

Cytogenetic analysis and clinical significance in adult T-cell leukemia/lymphoma: a study of 50 cases from the human T-cell leukemia virus type-1 endemic area, Nagasaki

Identification of cytogenetic abnormalities is an important clue for the elucidation of carcinogenesis. However, the cytogenetic and clinical significance of adult T-cell leukemia/lymphoma (ATLL) is still unclear. To address this point, cytogenetic findings in 50 cases of ATLL were correlated with clinical characteristics. Karyotypes showed a high degree of diversity and complexity. Aneuploidy and multiple breaks (at least 6) were observed frequently in acute and lymphoma subtypes of ATLL. Breakpoints tended to cluster at specific chromosomal regions, although characteristic cytogenetic subgroups of abnormalities were not found. Of these, aberrations of chromosomes 1p, 1q, 1q10-21, 10p, 10p13, 12q, 14q, and 14q32 correlated with one or more of the following clinical features: hepatosplenomegaly, elevated lactate dehydrogenase, hypercalcemia, and unusual immunophenotype, all indicators of clinical severity of ATLL. Multiple breaks (at least 6); abnormalities of chromosomes 1p, 1p22, 1q, 1q10-21, 2q, 3q, 3q10-12, 3q21, 14q, 14q32, and 17q; and partial loss of chromosomes 2q, 9p, 14p, 14q, and 17q regions correlated with shorter survival. These cytogenetic findings are relevant in predicting clinical outcome and provide useful information to identify chromosomal regions responsible for leukemogenesis. This study also indicates that one model of an oncogenic mechanism, activation of a proto-oncogene by translocation of a T-cell-receptor gene, may not be applicable to the main pathway of development of ATLL and that a multistep process of leukemogenesis is required for the development of ATLL. (Blood. 2001;97:3612-3620)

Evaluation of adult T-cell leukemia/lymphoma incidence and its impact on non-Hodgkin lymphoma incidence in southwestern Japan.

The incidence of adult T-cell leukemia/lymphoma (ATL) and its impact on that of total non-Hodgkin lymphoma (NHL) were evaluated in Nagasaki, an area in southwestern Japan where human T-cell lymphotropic virus type I (HTLV-I) is endemic. The first study area comprised 4 towns located on the K Islands, which had a population of 26,870 in 1990. The overall HTLV-I seroprevalence estimated from the serologic survey of 18,485 subjects was 16.2%. By using the data from the Nagasaki Prefectural Cancer Registry (NPCR) and reviewing clinical and laboratory information, we identified 40 cases of ATL and 35 cases of other NHL diagnosed between 1985 and 1995. The crude annual incidence of ATL among 100,000 HTLV-I carriers aged 30 or older was estimated at 137.7 for men and 57.4 for women, with a significant sex difference after adjustment for age (rate ratio = 2.50, 95% confidence interval 1.32-4.73). The cumulative risk from 30 to 79 years of age was estimated at approximately 6.6% for men and 2.1% for women. Among the entire population, ATL accounted for 51 to 59% of the total NHL incidence, showing the strong impact of HTLV-I infection. The second study area comprised the whole of Nagasaki Prefecture (total population in 1990 = 1.56 million). Between 1985 and 1995, 989 cases of ATL and 1,745 cases of other NHL were registered in the NPCR. The world age-standardized annual incidence rate of ATL per 100,000 persons aged 30 or older was estimated at 10.5 for men and 6.0 for women, which accounted for approximately 37 to 41% of the total NHL incidence.

Clinicopathologic analysis of 124 cases of adult T-cell leukemia/lymphoma with cutaneous manifestations: the smouldering type with skin manifestations has a poorer prognosis than previously thought.

Adult T-cell leukemia/lymphoma (ATLL) commonly involves the skin as well as peripheral blood and lymph nodes. During the last 15 years we have studied 124 cases of ATLL with specific skin manifestations. Twenty-one patients (16.9%) were classified as acute, 21 (16.9%) as chronic, 26 (21.0%) as lymphoma, and 56 (45.2%) as smouldering according to Shimoyama's classification. Many patients had nodules/tumors (34.7%), erythematous plaques (22.6%), and erythematous papules (19.4%) similar to those occurring with other cutaneous T-cell lymphomas. Some patients displayed characteristic skin manifestations resembling non-neoplastic cutaneous disorders. The median survival time (MST) of all patients was 12.0 months. The MSTs of individual clinical types were: acute type, 4 months; chronic type, 14 months; lymphoma type, 7 months; and smouldering type, 16 months. In the smouldering type, cases with a deeper infiltration pattern (MST, 14 months) had a more aggressive course than those with a superficial infiltration pattern (MST, 24 months) (p < 0.05). The results indicate that smouldering type ATLL with skin manifestations may have a worse prognosis than without skin manifestations. Moreover, some cases of the smouldering type with specific skin lesions should be classified into another group with a much poorer prognosis.

Geographic diversity of adult t-cell leukemia/lymphoma in Brazil

We describe 195 cases of adult T-cell leukemia/lymphoma (ATLL) reported to the national registry of T-cell malignancies in Brazil between 1994 and 1998. We compared the effect of demographic differences and clinical features of 150 consecutive ATLL cases in different regions of this diverse country. At diagnosis, the predominant clinical sub-type was the acute type (60%), followed by lymphoma (22%), chronic (10%) and smoldering (8%) types. Although we expected that different sub-types would be present in different regions, on the basis of immunogenetic factors determined by ethnicity, we did not demonstrate these differences. There were no significant differences among ATLL subtypes by age or gender. No ethnic group predominated in the total population of patients, but significant differences were noted when examining ethnic distribution by region. Reflecting the general population distribution, white patients were seen more often in São Paulo and black patients in Bahia, than in other regions. In most regions, cases were equally distributed between blacks and mulattos, except in Pernambuco, where blacks were less frequent. The main clinical features were lymphadenopathy, skin lesions, hypercalcemia and hepatomegaly. Fourteen patients (9%) suffered from HTLV-I-associated myelopathy (HAM/TSP), either at diagnosis or during follow-up of ATLL. All cases but one had antibodies to HTLV-I, with concordant results with ELISA, WB and PCR analyses. For the antibody-negative case, pol and tax gene sequences were present in tumor cells when subjected to PCR analyses. The prognosis was generally poor, suggesting that the disease in Brazil behaves in similar fashion regardless of ethnic or geographical differences.