Monoclonal Integration Research Articles

Clinicopathological features of cutaneous lesions of adult T-cell leukaemia/ lymphoma

Adult T-cell leukaemia/lymphoma (ATLL) is a human malignancy associated with human T-cell leukaemia virus type I (HTLV-I). ATLL frequently involves the skin. To correlate the clinicopathological features and prognosis in patients with ATLL and cutaneous lesions. We examined the HTLV-I proviral state and the clinicopathological features of the cutaneous lesions in 80 patients with serum anti-ATL antibody, to clarify the correlation between macroscopic/histopathological findings and prognosis. Southern blot analysis was performed in all cases to detect monoclonal HTLV-I proviral DNA integration. The cutaneous lesions of 46 patients were positive for proviral DNA integration. The median survival time of patients with monoclonal proviral DNA integration in cutaneous lesions was 14 months, which was markedly shorter than that of patients negative for proviral DNA integration (72 months). Of the 46 patients with proviral DNA, 21 had solitary or multiple red nodules (including three with subcutaneous induration), eight had multiple red papules and 17 had erythema. Patients with papules and nodules had poorer prognosis than those with erythema. Histopathologically, the prognosis was poorer in patients with nodular or diffuse infiltration of medium-sized to large lymphoma cells, compared with those with perivascular infiltration of small to medium-sized lymphoma cells. Our results show a close correlation between clinicopathological features of HTLV-I-associated cutaneous lesions and prognosis.

Primary Pulmonary T-cell Lymphoma in an HTLV-1 Carrier

Background. The incidence of primary pulmonary lymphomas is only 0.34%, and peripheral T-cell lymphoma is very rare. Moreover, there is no literature recording its appearance in a Human T lymphotropic virus type 1 (HTLV-1) carrier. Case. A 65-year old man with dry cough, fever, and chills was admitted with multiple pulmonary nodules and pleural effusion. High lymphocyte count and elevated adenosine deaminase (ADA) were found in the pleural effusion. Antitubercular therapy yielded no clinical or radiologic improvement. The patient was transferred to our hospital where lymphoma was confirmed from positive rearrangement of the TCR-β gene in cells in the pleural effusion. The patient was positive for HTLV-1 antibody, but did not have monoclonal integration of the pro-virus HTLV-1 in cells in the pleural effusion. Conclusion. This was the first case of an HTLV-1 carrier presenting with primary pulmonary T cell lymphoma.

Viral Infections in Juvenile Myelomonocytic Leukemia: Prevalence and Clinical Implications.

Viral infections may complicate the diagnosis of juvenile myelomonocytic leukemia (JMML) in a substantial proportion of patients, but this possibility has not been tested in a prospective study. The authors therefore measured the cellular expression of the MxA protein, a reliable marker of viral infection, at diagnosis in children with JMML to estimate the prevalence of such infections. Eighteen children, aged 1 to 69 months, who met the diagnostic criteria of the International JMML Working Group were prospectively studied. MxA expression was assessed by flow cytometric analysis of peripheral blood mononuclear cells stained with an antihuman MxA antibody. All data were obtained through the MDS Committee of the Japanese Society of Pediatric Hematology. Twelve patients (67%) had elevated levels of the MxA protein, with rotavirus, RS virus, or CMV infection documented in three of these patients. Although none of the patients had primary Epstein-Barr virus (EBV) infection, reactivation of the virus was strongly suspected in four children, including two with monosomy 7, each having increased levels of MxA. Southern blot analysis revealed monoclonal integration of the EBV genome into bone marrow mononuclear cells from one of these patients. There was no discernible correlation between increases in the marker protein and the presenting features or course of the disease. Viral infection may be present in two thirds of children with newly diagnosed JMML, but it does not constitute a basis for revising clinical management. The possibility that EBV or other viruses contribute to JMML pathogenesis by stimulating pre-exiting malignant clones warrants further investigation.

Colonic lymphomatous polyposis

A 58-year-old woman presented with diarrhea and lower abdominal pain of 2 weeks' duration. On examination, bilateral cervical and axillary lymph node enlargement was noted but not hepatosplenomegaly. The white blood cell count was 6600/mm3 (normal: 3500-8000/mm3), with a normal differential. Serum lactate dehydrogenase and calcium were within normal ranges. A test for serum antihuman T-lymphotropic virus type 1 (HTLV-1) antibody was positive. CT demonstrated enlargement of intra-abdominal lymph nodes. Evaluation of a cervical lymph node biopsy specimen revealed a diffuse infiltrate of abnormal lymphocytes, which contained multilobulated nuclei with condensed chromatin and agranular and basophilic cytoplasm. Monoclonal integration of HTLV-1 provirus in chromosomal DNA also was demonstrated. At colonoscopy, multiple polyps with a central depression were present throughout the colon (A), and biopsy specimens from these lesions consisted of a diffuse proliferation of abnormal appearing lymphocytes with hyperchromatic and highly convoluted nuclei (B; H&E, orig. mag. ×400). Immunohistochemically, these neoplastic cells were negative for the B-cell markers CD20 and CD79a, but positive for the T-cell markers CD3 and UCHL-1 (C; immunohistochemical stain, orig. mag. ×400). No abnormality was found by upper endoscopy or by barium contrast radiography of the small intestine. Thus, a diagnosis of a lymphoma subtype of adult T-cell leukemia/lymphoma with colonic involvement resembling multiple lymphomatous polyposis was established. The patient was treated with vindesine, cyclophosphamide, and doxorubicin but died 7 months after commencement of treatment.

Cutaneous type of adult T cell leukemia/lymphoma: a new entity among cutaneous lymphomas.

Adult T cell leukemia/lymphoma (ATL) is a malignancy of CD4+ T cells that is endemic in certain areas in Japan. Two types of cutaneous ATL thought to originate from skin include cutaneous tumor and erythematopapule types. Patients with cutaneous ATL show neither leukemic involvement nor invasion of tumor cells into the lymph nodes for at least six months. The differential diagnosis between cutaneous ATL and mycosis fungoides is often difficult. The presence of monoclonal integration of human T lymphotropic virus-I proviral DNA in skin samples is of definitive diagnostic value in cutaneous ATL.

Monoclonally integrated HTLV type 1 in epithelial cancers from rabbits infected with an HTLV type 1 molecular clone.

In addition to T cell leukemias and lymphomas, human T cell leukemia virus type 1 (HTLV-1) infection has been associated with nonhematologic malignancies and described as the cause of one case of small-cell lung carcinoma. Infected primary epithelial cells have been isolated from sweat gland and oral mucosae of HTLV-1-infected human patients. In the present study, epithelial neoplasms developed in two rabbits experimentally infected with a molecular clone of HTLV-1 (strain K30p). Serologic detection of anti-HTLV-1 and isolation of virus from blood lymphocytes at multiple time points postinjection established a course of chronic asymptomatic infection in both. One rabbit, infected for 5.5 years after intramuscular injection of HTLV-1 DNA, developed a thymoma having features of medullary differentiation. HTLV-1 provirus was detected in both thymocytes and neoplastic epithelium isolated discretely from the thymoma by laser capture microdissection. These findings provide the first experimental evidence of HTLV-1 disease after infection by HTLV-1 DNA injection. Endometrial adenocarcinoma occurred in a second rabbit 2.5 years after its inoculation with cell-associated virus. In this second case, an epithelial cell line derived ex vivo from a metastatic lesion produced virus in culture. In tumors from each of the two rabbits, the neoplastic epithelium was infected and harbored monoclonally integrated HTLV-1 provirus. Although monoclonal provirus integration alone does not establish retroviral cause of carcinogenesis unequivocally, these and other accumulating data indicate that there may be a role for HTLV-1 in diseases associated with infection of epithelia, including some epithelial cancers.

Primary Gastric T-cell Lymphoma Associated with Human T-cell Leukemia Virus Type I shows 'Lymphoepithelial Lesions': Case report.

We describe an unusual case of adult T-cell leukemia/lymphoma (ATL) appearing in a 44-year-old female without leukemic change and systemic lymphadenopathy, which originated from the gastric wall and partially involved the paragastric lymph nodes. No other intraabdominal or intrathoracic organs, such as the liver, spleen, kidneys, adrenals, lungs, or bone marrow, were involved at the time of surgery. The clinical stage of this case was evaluated as IIE according to the Ann Arbor classification. Lymphoma cells were CD3+, CD4+, CD8-, and CD79a-. Southern blot analysis revealed monoclonal integration of proviral DNA from human T-cell leukemia virus type I. Interestingly, the lymphoma cells formed ‘lymphoepithelial lesions’ which are usually observed in gastric mucosa-associated lymphoid tissue (MALT) B-cell lymphomas. A rare pattern involving ATL cells and the presence of lymphoepithelial lesions in this case indicated a diagnostic pitfall of gastric MALT lymphoma.

Adult T-Cell Leukemia/Lymphoma and Cluster of HTLV-I Associated Diseases in Brazilian Settings

We studied the transmission routes of human T-cell lymphotropic virus type I (HTLV-I) within families of 82 Brazilian patients diagnosed with adult T-cell leukaemia/lymphoma (ATL). Diagnosis of ATL in 43 male and 39 female patients was based on clinical and laboratory criteria of T-cell malignancy and detection of HTLV-I monoclonal integration. Samples were tested for HTLV antibodies and infection was confirmed as HTLV-I by Western Blot and/or polymerase chain reaction (PCR) assays. Overall 26/37 (70%) of mothers, 24/37 (65%) of wives, 8/22 (36%) of husbands, 34/112 (30%) of siblings and 10/82 (12%) offspring were HTLV-I infected. In 11 ATL patients, mothers were repeatedly HTLV-I seronegative, but HTLV-I pol or tax sequences were detected in 2 out of 6 cases tested by PCR. ATL patients with seronegative mothers related the following risk factors for HTLV-I infection: 6 were breast-fed by surrogate mothers with unknown HTLV-I status, 4 had a sexually promiscuous behaviour and 1 had multiple blood transfusions at a young age. Familial aggregation of ATL and other HTLV-I associated diseases such as HTLV-I myelopathy (HAM/TSP) and or uveitis, ATL in sibling pairs or in multiple generations was seen in 9 families. There were 6 families with ATL and TSP sibling pairs. In 3 families at least one parent had died with lymphoma or presenting neurological diseases and 2 offspring with ATL. Further to the extent of vertical and horizontal transmission of HTLV-I infection within ATL families, our results demonstrate that mothers who provide surrogate breast-milk appear to be an important source of HTLV-I transmission and ATL development in Brazil.

CD20‐positive adult T‐cell leukemia

A 67-year-old woman was admitted to our hospital because of lymphadenopathy and lymphocytosis. Monoclonal integration of HTLV-I provirus DNA was detected, and a diagnosis of adult T-cell leukemia (ATL) was made. Flow cytometry revealed that the ATL cells expressed CD20 as well as T-cell-associated antigens, and expression of CD20 mRNA was also demonstrated. A novel T-cell subpopulation expressing CD20 molecules has recently been identified. This is the first report of CD20-positive ATL, suggesting that HTLV-I can infect and transform CD20-positive T cells. Am. J. Hematol. 66:39–41, 2001. © 2001 Wiley-Liss, Inc.

Human T-lymphotropic virus type 1 infection

Human T-cell lymphotropic virus type-1 (HTLV-1) is aetiologically associated with adult T-cell leukaemia/lymphoma (ATL). HTLV-1 infection can also lead to various non-malignant diseases, for example, HTLV-1 associated myelopathy/tropical spastic paraparesis and HTLV-1 uveitis. HTLV-1 is endemic in southern Japan and the Caribbean. HTLV-1 infection is mainly transmitted by either breast-feeding, sexual intercourse or blood transfusions. Primary prevention of HTLV-1 in endemic areas by screening of blood and by refraining from breast-feeding have been successful. The incidence of ATL is rather low among HTLV-1 carriers (<5%). The precise mechanism of development of ATL remains unknown. It is a multiple-step process which does not require viral expression in the later stages of leukaemogenesis. Many samples have mutations of the tumour suppressor genes, p53 and/or p16INK4A. Four subtypes of ATL have been identified, each having distinctive clinical features. Monoclonal integration of HTLV-1 proviral DNA into tumour cells is found in each of the subtypes. At present, no effective therapy for ATL exists.

Spontaneous Remission in Acute Type Adult T-Cell Leukemia/Lymphoma

Adult T-cell leukemia/lymphoma (ATL) is a neoplastic disorder of T lymphocytes associated with human T lymphotropic virus type I (HTLV-I). The prognosis of ATL is generally poor. We present here a 79-year-old woman with spontaneous remission of acute type ATL. Spontaneous remission was preceded by surgical biopsy and pneumonia and lasted for two years until she died with pancreas cancer. Monoclonal integration of HTLV-I provirus DNA became undetectable after remission.

Absence of cytotoxic molecules in CD8- and/or CD56-positive adult T-cell leukaemia/lymphoma.

Adult T-cell leukaemia/lymphoma (ATLL) cells usually exhibit a CD4+ (helper/inducer) phenotype (CD4+/8-/56-), and only a minority of tumours express the CD8 (cytotoxic/suppressor) or CD56 (natural killer [NK]-associated) antigens. TIA-1 is a cytotoxic granule-associated protein expressed in NK cells and cytotoxic T lymphocytes (CTLs). Granzyme B, perforin and Fas ligand (FasL) are also expressed in activated CTLs and NK cells. To clarify the cytotoxic potential of ATLL cells, immunohistochemistry was performed in CD8+ and/or CD56+ ATLL cells, using anti-TIA-1, anti-granzyme B, anti-perforin and anti-FasL antibodies. We studied nine cases of CD8+ and/or CD56+ ATLL, all of which exhibited monoclonal integration of human T-cell leukaemia virus type 1 (HTLV-1) proviral DNA. Four cases exhibited a CD8+/CD56- phenotype, four others had a CD8-/CD56+ phenotype, and one was CD8+/CD56+. All but one case also expressed the surface antigens CD3, TCR alpha beta, and CD4. Expression of granzyme B and TIA-1 were demonstrated in three and two cases, respectively, but none expressed perforin or FasL. In the control study, 10 cases with typical CD3+/4+/8-/56- ATLL demonstrated no expression of those cytotoxic-associated proteins. Our findings suggest that CD8 and/or CD56 positivity probably confer(s) no cytotoxic function on ATLL cells, and it is possible that CD8 and CD56 may be simply aberrant surface markers in ATLL.

Rapid quantification of HTLV-I provirus load: detection of monoclonal proliferation of HTLV-I-infected cells among blood donors.

In this report, we quantified HTLV-I provirus load using the AmpliSensor system, which utilizes fluorescence to measure PCR products. With this method, provirus loads could be measured within 6 hr, and the results obtained correlated well with those obtained by other methods. Samples from 256 blood donors, who were positive for antibodies against HTLV-I, were analyzed, showing that provirus load ranged from less than 0.1% to 56% among carriers. We analyzed the association between provirus load and the biomarkers age and sex and found that it was not influenced by either. Provirus load was better correlated with soluble interleukin-2 receptor (sIL-2R) levels than with antibody titer against the virus. Among 18 blood donors with high provirus load (more than 10%), Southern blotting detected monoclonal integration of HTLV-I in infected cells in 2 cases, both of them showing high sIL-2R levels (more than 900 U/ml). Sequential analyses of provirus load showed stable levels of provirus in the same carriers, suggesting that some factors other than age or sex determined provirus load in infected individuals. Thus, this rapid method is a useful tool for the early detection of adult T-cell leukemia and other HTLV-I-associated diseases.

Rapid quantification of HTLV‐I provirus load: Detection of monoclonal proliferation of HTLV‐I‐infected cells among blood donors

In this report, we quantified HTLV-I provirus load using the AmpliSensor system, which utilizes fluorescence to measure PCR products. With this method, provirus loads could be measured within 6 hr, and the results obtained correlated well with those obtained by other methods. Samples from 256 blood donors, who were positive for antibodies against HTLV-I, were analyzed, showing that provirus load ranged from less than 0.1% to 56% among carriers. We analyzed the association between provirus load and the biomarkers age and sex and found that it was not influenced by either. Provirus load was better correlated with soluble interleukin-2 receptor (sIL-2R) levels than with antibody titer against the virus. Among 18 blood donors with high provirus load (more than 10%), Southern blotting detected monoclonal integration of HTLV-I in infected cells in 2 cases, both of them showing high sIL-2R levels (more than 900 U/ml). Sequential analyses of provirus load showed stable levels of provirus in the same carriers, suggesting that some factors other than age or sex determined provirus load in infected individuals. Thus, this rapid method is a useful tool for the early detection of adult T-cell leukemia and other HTLV-I-associated diseases. Int. J. Cancer 81:859–864, 1999. © 1999 Wiley-Liss, Inc.

Defective human T‐lymphotrophic virus type I provirus in T‐cell prolymphocytic leukaemia

T-cell prolymphocytic leukaemia (T-PLL) is a rare form of post-thymic T-cell neoplasm, the aetiology of which remains unknown. We examined human T-lymphotropic virus (HTLV) provirus in five HTLV-I/II seronegative patients with T-PLL. Southern blotting did not show monoclonal integration of the HTLV-I genome in any of the DNA samples. However, two of the five DNA samples contained an HTLV-I tax sequence. Other sets of oligonucleotide primers for HTLV-I gag, pol, env and LTR regions were all negative. HTLV-I tax gene expression and p40tax antibody were not detected in samples from cases with HTLV-I tax sequence. Our findings suggest that there may be alternative mechanisms involved in HTLV-associated leukaemogenesis, in which HTLV-I genome insertion triggers T-PLL but the deletion of various regions of the integrated provirus subsequently prevents active replication and the expression of the virus.

CLINICOPATHOLOGICAL ASPECTS OF 26 CASES OF CUTANEOUS ATL IN BAHIA, BRAZIL

P127 We present 26 cases of ATL primary of the skin. The median age of the patients was 46.8 y. One patients was- a child. The relation male/female was 2.2. All the patients were black or mulattos. The median time of duration of disease prior to diagnosis and follow-up was respectively 2.35 y and I, 83 y. The clinical form was: smoldering (10 cases), acute (6), lymphoma (3), chronic (3) and 4 cases that presented tumoral skin lesions without leukemia and involvement of other organs. Two smoldering cases evolved to acute disease during follow-up. The lesions appeared as: erythroderma, papules, infiltrated plaques, nodules and tumors. All the cases, except one, exhibited disseminated lesions. Morphologically, the cases were diagnosed as pleomorphic lymphoma (15 cases), mycosis fungoides (10) and large cell anaplastic lymphoma (1). Monoclonal integration of HTLV-I was demonstrated by southern blot in 8 cases. HTLV-I+ cutaneous lymphoma in Bahia presents some peculiar aspects: I) A more protracted course, predominance of the smoldering form; 2) Lower median age and occurrence in children; 3) Erythroderma as the most frequent lesion; 4) Presence of other histopatological patterns besides pleomorphic T lymphoma (the classical histologic form of ATL); 5) Primary skin tumors without leukemia and involvement of other organs.

THE OVERLLAPING OF ATLL AND TSP/HAM. EXPERIENCE OF THE BRAZILIAN ATLL STUDY GROUP

P137 Recently we described 195 cases of ATLL reported to the national registry of T-cell malignancies and HTLV-I infection in Brazil and one of the notable feature of these series was the presence of 15 patients (9 males and 6 females) with both HTLV-I associated diseases (ATL and TSP/HAM). Demographic breakdown of this group shown that 12 patients were born in Northeast of Brazil and male-female ratio was 2:1. These patients suffered from difficulty in walking, sphincter disturbance and spastic paraparesis of the lower limbs, hyperreflexia and brisk reflexes. HTLV-I antibodies and tax and pol gene sequences was detected in both peripheral blood and CSF cells. The diagnosis of both disease was made either at diagnosis or during follow-up of ATLL. Southern blot analysis demonstrated HTLV-1 monoclonal integration in 8 cases studied. Eight patient had suffered from myelopathy more than 4 years prior to the diagnosis of ATLL and two of these patients were brother and sister part of a family with 10 individuals with HTLV-1 infection. Further immunological and molecular studies of such cases should provide valuable insights in the pathogenesis of HTLV-1 associated diseases.

CLINICAL, PATHOLOGICAL, IMMUNOHISTOCHEMICAL AND GENETIC DIFFERENCES BETWEEN MYCOSIS FUNGOIDES (MF) AND MF-LIKE ADULT T-CELL LYMPHOMA/LEUKEMIA(ATLL).

P132 MF-like ATLL is characterized by the involvement of the skin alone for years or decades, positiveness for antibody against human T-lymphotropic virus type 1 [HTLV-1 Ab(+)] and demonstration of monoclonal integration of HTLV-1 provirus in the skin lesions [HTLV-1 proviral DNA(+)]. Clinical, pathological, immunohistochemical and genetic studies were performed in fifteen cases of MF revealing HTLV-1 Ab(−), in 2 cases of MF showing HTLV-1 Ab(+) and HTLV-1 proviral DNA(−), and in 15 cases of MF-like ATLL. The age at the onset of the disease was significantly younger in MF than in ATLL, and the duration of erythematous and plaque stage was significantly longer in MF than in ATLL. The survival of patients, calculated by the generalized Wilcoxon test, was better in MF than in ATLL at 1 % of risk rate. In the erythematous and plaque stages, Pautrier's microabscesses were more abundant and larger in ATLL than in MF, and the nuclei of tumor cells were darker in MF than in ATLL histopathologically. The phenotypes of ATLL cells were constantly CD3+, CD4+, CD8−, CD25+, CD45RA−. CD45RO+. In contrast, MF cells revealed CD3+, CD4+, CD8−, CD25−, CD45RA+. CD45RO− of phenotype in the erythematous and plaque stages. Two cases of MF developing among HTLV-1 carrier revealed the same results in all issues as in cases of MF. HTLV-1 proviral DNA(+) was demonstrated in skin lesions alone and both of skin and peripheral blood lymphocytes at 30% and 70%, respectively. These data suggest that ATLL will be a different disease from MF, even when the two diseases show similar clinical pictures.

Nasal Lymphomas in Japan: A High Prevalence of Epstein-Barr Virus Type A and Deletion Within the Latent Membrane Protein Gene

The majority of nasal lymphomas are of the natural killer (NK)/T cell lineage. We analyzed 33 specimens of nasal lymphoma from Japanese patients for Epstein-Barr virus (EBV). Phenotypic and genetic analyses showed 28 cases with NK/T cell type and 5 cases with B cell type. All NK/T lymphomas were of pleomorphic cell type except 2 large cell (centroblastoid) and one lymphoblastic lymphoma. All cases with nasal B cell lymphoma were of large (centroblastoid) cell type. EBV was detected in all cases of NK/T cell type with the exception of one lymphoblastic case, and was monoclonally integrated in all cases examined (14/14 cases). All but one case had subtype A of EBV infection with 30-base paired deleted LMP-1 gene. One case of B cell lymphoma showed the presence of EBV infection with subtype A and deletion of LMP-1. Our results indicate that the majority of nasal lymphomas in Japanese patients are of the nasal NK/T cell type, have pleomorphic morphology, a high prevalence of EBV with a monoclonal integration, subtype A and deleted LMP-1 gene. In contrast, nasal B cell lymphoma showed monomorphic appearance and rare EBV infection.

Adult T Cell Leukemia Lymphoma (ATL) Localized in the Right Tibial Bone

A 56-year-old man was admitted complaining of pain in the right tibia. He was diagnosed as having adult T-cell leukemidymphoma (ATL/L) in the right knee joint by roentgenographic and histological examination. Monoclonal integration of HTLV-I proviral DNA was demonstrated in the bone tumor cells, although polyclonal integration was observed in the peripheral blood. These results led us to make a diagnosis of ATL with localized growth in the right knee joint. The osteolytic bone change was progressive despite radiation therapy. Complete remission was achieved after amputation of his right lower leg and two courses of chemotherapy. Resection of the localized lesion might be useful in cases of ATL, but further studies are necessary to confirm this conclusion.