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Hematopathology / HEPATOSPLENIC T-CELL LYMPHOMA IN BONE MARROW
Hepatosplenic gamma/delta T-Cell Lymphoma in Bone
Marrow
A Sinusoidal Neoplasm With Blastic Cytologic Features
Francisco Vega, MD, PhD,* L. Jeffrey Medeiros, MD, Carlos Bueso-Ramos, MD, PhD,
Dan Jones, MD, PhD, Raymond Lai, MD, PhD, Rajyalakshmi Luthra, PhD, and
Lynne V. Abruzzo, MD, PhD
Key Words: Bone marrow; gamma/delta T-cell receptor; Hepatosplenic T-cell lymphoma; Immunophenotype
Abstract
We report 8 cases of hepatosplenic T-cell
lymphoma (HSTCL) involving bone marrow and
correlate histologic findings with disease progression.
Immunophenotypic analysis demonstrated mature,
aberrant gamma/delta T-cell immunophenotypes.
Isochromosome 7q was identified in 4 cases; 1 case
showed the t(7;14)(q34;q13). Seven of 7 cases tested
had monoclonal TCR gamma gene rearrangements.
The initial diagnostic bone marrow biopsy specimens
were hypercellular with a frequently subtle,
predominantly sinusoidal infiltrate of atypical small to
medium-sized lymphoid cells. In all cases, aspirate
smears at diagnosis and in subsequent specimens
contained malignant cells that resembled blasts, some
with fine cytoplasmic granules. With progression, the
pattern of HSTCL in bone marrow biopsy specimens
became increasingly interstitial, and the neoplastic
cells became larger. In aspirate smears, the proportion
of blasts increased. Seven patients died; 1 was lost to
follow-up. Autopsy performed on 1 patient
demonstrated malignant cells within vascular channels
in all organs sampled, with relatively little tumor
formation, resembling intravascular lymphoma at these
sites. HSTCL often can be recognized in bone marrow
by its unique combination of a sinusoidal pattern in
core biopsy specimens and blastic cytology in aspirate
smears.
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Am J Clin Pathol 2001;116:410-419
Hepatosplenic T-cell lymphoma (HSTCL) is an
uncommon form of peripheral T-cell lymphoma.1,2 In 1981
Kadin et al3 described 2 cases of an unusual T-cell lymphoma
that they termed erythrophagocytic T-gamma lymphoma.
These cases have many of the clinical and histologic features
of HSTCL and may represent the first description of HSTCL
in the literature. Patients with HSTCL usually are young men
with hepatosplenomegaly, clinically significant cytopenias,
and minimal or absent lymphadenopathy; they have a rapidly
progressive clinical course and poor prognosis.1,2,4,5 The
neoplastic cells preferentially infiltrate hepatic and bone
marrow sinusoids and splenic red pulp.1,5 Immunophenotypic
studies have shown that the neoplastic cells have an aberrant
T-cell immunophenotype and usually have an inactive cytotoxic profile, ie, positive for TIA-1 and negative for
granzyme B and perforin.5,6 Isochromosome 7q is a consistent cytogenetic abnormality.5,7-9 Because of its characteristic
clinical, histologic, and immunophenotypic features, HSTCL
was proposed as a provisional entity in the Revised European-American Classification of Lymphoid Neoplasms and is
now recognized as a distinct clinicopathologic entity in the
proposed World Health Organization classification
system.10,11 Although most cases express the gamma/delta Tcell receptor (TCR), some cases reported have expressed the
alpha/beta TCR.12
Bone marrow involvement in HSTCL is common,4,5 and
patients often have thrombocytopenia and anemia. As a
result, bone marrow biopsy and aspiration often are the first
procedures performed. However, the histologic features of
HSTCL in bone marrow specimens may be subtle and have
not been clearly described. We report the clinicopathologic
features of 8 cases of gamma/delta HSTCL involving bone
marrow and emphasize the changes in histologic findings that
occur with disease progression.
© American Society of Clinical Pathologists
Hematopathology / ORIGINAL ARTICLE
Materials and Methods
Six patients (cases 1-4, 7, and 8) were referred to the
University of Texas M.D. Anderson Cancer Center, Houston,
for evaluation and treatment. H&E-stained histologic
sections and Wright-Giemsa–stained smears were prepared
at the submitting institutions. Additional sections were
prepared from submitted paraffin blocks of formalin-fixed
tissue. Two patients (cases 5 and 6) were evaluated and
treated at the University of Maryland Medical Center, Baltimore; their clinical and pathologic features have been
reported previously.9
Immunohistochemical stains were performed using
fixed, paraffin-embedded tissue sections, an avidin-biotinperoxidase complex method, and an automated immunostainer (Ventana-Biotech, Tucson, AZ). All tissue sections
underwent heat-induced antigen retrieval. The antibodies
used were specific for factor VIII–related antigen (1:400),
CD45RB (1:300, leukocyte common antigen), CD79a
(1:50), CD3 (1:150), CD20 (1:700, L26), and terminal
deoxynucleotidyl transferase (TdT; 1:20) (DAKO, Carpinteria, CA); CD43 (1:20, Leu22), CD34 (1:20), and CD15
(1:20, LeuM1) (Becton Dickinson, San Jose, CA); CD56
(1:15; Sanbio, Uden, the Netherlands); and cytotoxic
granule–associated protein (1:25, TIA-1; CoulterImmunotech, Miami, FL).
Immunophenotypic analysis by flow cytometry was
performed on bone marrow aspirate specimens according to
standard methods. A variable panel of antibodies was used,
including those reactive with CD2, CD3, CD4, CD5, CD7,
CD8, CD16, CD56, CD57, CD10, CD19, CD20, CD22,
CD23, CD34, TCR alpha/beta, TCR gamma/delta, TdT, and
immunoglobulin kappa and lambda light chains.
In situ hybridization analysis for Epstein-Barr virus was
performed on bone marrow biopsy specimens using a DAKO
hybridization kit (ref Y5200) according to the manufacturer’s instructions with the appropriate positive and negative
controls.
Cytogenetic studies were performed on direct preparations of bone marrow at the M.D. Anderson Cancer Center
(cases 1, 3, 7, and 8) and the University of Maryland (cases 5
and 6) using standard techniques.
Molecular genetic studies to assess for rearrangement
of the TCR gamma chain gene were performed in 7 cases
using polymerase chain reaction (PCR) methods and
formalin-fixed, paraffin-embedded tissue. In 2 cases (cases
5 and 6), the products were detected using standard
methods.9 In 5 cases (cases 1-4 and 7), the products were
analyzed by high-resolution capillary electrophoresis using
a 310 Genetic Analyzer (PE/Applied Biosystems, Foster
City, CA), as described previously. 13 In contrast with
conventional primers, each of the 4 forward primers was
© American Society of Clinical Pathologists
labeled at its 5' end with 1 of 4 fluorescent dyes. The
forward primer for the V-gamma-I family was labeled with
tetramethyl-6-rhodamine (TAMRA). The forward primers
for the V-gamma-II, V-gamma-III, and V-gamma-IV families were labeled with 6-carboxyfluorescein (FAM), hexachloro-6-carboxyfluorescein (HEX), and tetrachloro-6carboxyfluorescein (TET), respectively. The labeled
fluorescent dyes and the unlabeled primers were obtained
from Life Technologies (Gaithersburg, MD). An aliquot
(0.25 µL) of each fluorescently labeled PCR product was
incubated for 10 minutes at 95°C with 12 µL of deionized
formamide and 1 µL of the internal size standard (GeneScan
TAMRA-500, PE/Applied Biosystems). Another 0.25-µL
aliquot of each sample was incubated with 13 µL of deionized formamide without the size standard to simplify interpretation. Subsequently, samples were loaded on a DNA
sequence analyzer (PRISM 310, PE/Applied Biosystems).
The samples were separated using a 30-cm capillary tube
that contained a performance-optimized polymer matrix
(POP4, PE/Applied Biosystems). Injection was carried out
for 5 seconds at 15 kV; electrophoresis was performed at 15
kV for 24 minutes at 60°C. Fluorescence data were
analyzed using GeneScan 3.1 software (PE/Applied Biosystems) and Genotyper software (PE/Applied Biosystems) to
determine the size and relative abundance of each fluorescently labeled product.
Results
Clinical Findings
The clinical features are summarized in ❚Table 1❚. Six
patients were male, 2 were female, and their ages ranged
from 15 to 64 years (median, 37 years). The interval from
onset of symptoms to diagnosis ranged from 1 to 10 months
(median, 2.8 months). Physical examination at the time of
diagnosis revealed splenomegaly in all patients and
hepatomegaly in 6 patients. Only 1 patient (case 6) had
peripheral lymphadenopathy; axillary and inguinal lymph
node biopsy specimens demonstrated reactive hyperplasia.
Although CBCs were not available for some patients, most
were reported to have thrombocytopenia and anemia at the
time of diagnosis, and only 1 patient (case 6) was reported to
have slight lymphocytosis.
All patients received aggressive multiagent chemotherapy after the diagnosis of HSTCL was established. One
patient (case 4) experienced a complete clinical remission for
5 months, but then experienced relapse and died 13 months
after diagnosis. Seven patients (cases 2-8) had progressive
disease despite therapy and died 2 to 25 months after diagnosis. One patient (case 1) was lost to follow-up.
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Vega et al / HEPATOSPLENIC T-CELL LYMPHOMA IN BONE MARROW
❚Table 1❚
Clinical Findings at Diagnosis
Involvement
Case No./Sex/
Age (y)
1/M/64
2/M/25
3/F/27
4/M/52
5/M/15
6/M/37
7/F/43
8/M/35
*
Anemia
Decreased
Platelet Count
Hepatomegaly
Splenomegaly
+
+
+
NA
+
+
NA
+
+
+
+
+
+
+
NA
+
+
+
+
NA
+
+
–
+
+
+
+
+
+
+
+
+
Lymph
Node
–
–
–
–
–
–*
–
–
Skin
Peripheral
Blood
–
–
–
–
–
–
–
–
+
+
+
NA
+
+
NA
–
Outcome
Lost to follow-up
DOD, 10 mo
DOD, 5 mo
DOD, 13 mo
DOD, 25 mo
DOD, 7 mo
DOD, 12 mo
DOD, 2 mo
Axillary and inguinal lymph node biopsies showed reactive hyperplasia.
Histologic Findings
Bone marrow core biopsy sections and aspirate smears
were reviewed for all cases. The initial diagnostic bone
marrow specimens were reviewed in 7 of 8 cases (cases 1-3,
5-8), and specimens obtained after diagnosis were reviewed
in 8 cases.
The initial biopsy sections were hypercellular and
contained sinusoidal and interstitial infiltrates of atypical
small to medium-sized lymphoid cells ❚Image 1A❚. The
pattern of infiltration at diagnosis was predominantly sinusoidal in 6 cases (cases 2, 3, and 5-8) and predominantly
interstitial in 1 case (case 1). The neoplastic cells had a
tendency to almost imperceptibly percolate between normal
hematopoietic cells. This pattern of infiltration was
frequently subtle and difficult to detect in routine H&Estained sections but was accentuated by immunohistochem-
ical stains for T-cell antigens ❚Image 1B❚ . The small
neoplastic cells possessed nuclei with irregular contours
and coarse chromatin. The medium-sized neoplastic cells
had more open chromatin and frequently small but conspicuous nucleoli. Both the small and larger cells had a
moderate amount of basophilic cytoplasm with indistinct
cell borders. Scattered mitotic figures were seen in all
cases.
The hematopoietic bone marrow was hypercellular with
trilineage hyperplasia and large hyperlobated megakaryocytes in all cases. Slight dyserythropoiesis was common,
but multilineage dysplasia was not observed and ringed
sideroblasts were not seen. Slight to moderate plasmacytosis
was seen in 5 cases (cases 2, 3, and 6-8). In addition, all
cases contained conspicuous branching and tortuous blood
vessels ❚Image 2❚, and hyperlobated megakaryocytes were
A
B
❚Image 1❚ (Case 3) A, At diagnosis the bone marrow showed a predominantly intrasinusoidal infiltrate of small cells with coarse
chromatin (H&E, original magnification ×1,000). B, Antibody to CD3 accentuated the neoplastic cells (CD3, original
magnification ×400).
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Am J Clin Pathol 2001;116:410-419
© American Society of Clinical Pathologists
Hematopathology / ORIGINAL ARTICLE
❚Image 2❚ (Case 1) At the time of diagnosis the bone marrow
showed numerous branching and tortuous blood vessels
(factor VIII–related antigen, original magnification ×200).
seen within many of these vessels. Erythrophagocytosis by
histiocytes was seen in 4 cases (cases 2, 3, 4, and 8).
With disease progression, the degree of interstitial infiltration ❚Image 3A❚ and ❚Image 3B❚ and the percentage of
medium to large cells increased ❚Image 3C❚, although a
subpopulation of small atypical cells with irregular nuclear
contours and coarse chromatin were still observed ❚Table 2❚.
Over the disease course, mitotic figures were found more
easily. Residual foci of hematopoietic cells were indistinctly
demarcated from the atypical lymphoid infiltrate.
Differential nucleated cell counts (100 cells) were
performed on Wright-Giemsa–stained aspirate smears. In all
cases, 2 populations of atypical cells were identified: small
cells and medium to large cells ❚Image 4❚. The nuclei of the
small cells had irregular contours, condensed chromatin, and
inconspicuous nucleoli. The medium to large cells had nuclei
with irregular contours, moderately dispersed chromatin, and
conspicuous nucleoli. These cells had a moderate amount of
basophilic cytoplasm that occasionally contained a few fine
cytoplasmic granules. Over the course of disease, the
percentages of neoplastic cells and blastic cells increased
(Table 2). In 1 case (case 8), the blasts formed cohesive clusters in aspirate smears.
CBCs were not available for all patients, but peripheral
blood smears prepared at the time of diagnosis were available
for review in 6 cases (cases 1-3, 5, 6, and 8). Although only 1
patient was reported to have a slight lymphocytosis (case 6),
Wright-Giemsa–stained peripheral blood smears contained
neoplastic cells that were cytologically similar to those seen
in the bone marrow in 5 cases (cases 1-3, 5, and 6). These
cells constituted from 1% to 17% of all lymphocytes.
© American Society of Clinical Pathologists
One patient (case 4) developed an erythematous maculopapular rash on his upper arms and shoulders 11 months
after diagnosis. A skin biopsy demonstrated an infiltrate of
atypical lymphoid cells within the papillary dermis and
surrounding blood vessels, with marked epidermotropism
❚Image 5A❚. Atypical lymphoid cells also were seen within
the lumina of small blood vessels in the superficial and deep
dermis ❚Image 5B❚. The atypical lymphocytes were medium
to large with dense, clumped chromatin; inconspicuous
nucleoli; irregular (but not cerebriform) nuclear contours;
and scant cytoplasm. The infiltrate lacked admixed inflammatory cells.
An autopsy performed in case 3 revealed neoplastic
cells within capillaries and dilated small to medium-sized
blood vessels in liver, spleen, lymph nodes, and bone
marrow most extensively, but also throughout the body
❚Image 6A❚ and ❚Image 6B❚ . These findings resembled
intravascular lymphoma at these sites.
Results of Immunophenotypic Analysis and In Situ
Hybridization
The results of immunophenotypic studies are summarized in ❚Table 3❚. In all cases, the neoplastic cells displayed a
mature, aberrant, T-cell immunophenotype. In all cases tested,
the neoplastic cells expressed CD2 (8/8), CD3 (8/8), TIA-1
(7/7), and TCR gamma (7/7). These neoplasms also were
commonly positive for CD7 (7/8) and CD56 (7/8). Two cases
were positive for CD8 (2/8), 1 was positive for CD5 (1/8), and
all were negative for CD4 (0 of 8 positive). CD16 was positive
in 3 of 6 cases assessed. All cases were negative for CD19,
CD20, immunoglobulin light chains, and markers of myeloid
differentiation. In situ hybridization for Epstein-Barr virus
RNA was negative in all cases tested (6/6). The neoplastic
cells that infiltrated the skin in patient 4 expressed CD3,
CD56, and TIA-1, similar to the cells in the bone marrow.
Cytogenetic Findings
Cytogenetic analysis was performed on initial diagnostic
bone marrow aspirates in 6 cases. Isochromosome 7q was
detected in 4 cases (cases 1, 5, 6, and 8). In addition to the
isochromosome 7q, trisomy 8 was identified in case 1, and loss
of chromosomes 21 and Y and del(11)(q14) were found in
case 6. In case 7, cytogenetic analysis identified the
t(7;14)(q34;q13) and del(2)(q32;q37). All of these patients
were mosaic, with a cytogenetically normal cell population and
an abnormal population. In case 3, no apparent abnormal clone
was identified. However, the bone marrow aspirate was diluted
with peripheral blood and contained few neoplastic cells.
Molecular Diagnostic Studies
Molecular genetic studies for rearrangement of the TCR
gamma chain gene were performed in 7 cases, and all
Am J Clin Pathol 2001;116:410-419
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Vega et al / HEPATOSPLENIC T-CELL LYMPHOMA IN BONE MARROW
A
B
❚Image 3❚ With disease progression the degree of interstitial
infiltration and the percentage of medium to large cells
increased. A (Case 1), Four months after diagnosis, the bone
marrow biopsy specimen contained an extensive interstitial
infiltrate composed of medium-sized cells with open chromatin
(H&E, original magnification ×200). B (Case 1), Antibody to the
cytotoxic granule-associated protein TIA-1 accentuated the
interstitial infiltrate (TIA-1, original magnification ×400). C
(Case 3), Six months after diagnosis, the infiltrate was still
predominantly sinusoidal, but the neoplastic cells were large
with open chromatin, conspicuous nucleoli, and many mitotic
figures (H&E, original magnification ×1,000).
C
contained monoclonal rearrangements. Five cases (cases 1-4
and 7) had monoclonal rearrangements detected by highresolution GeneScan analysis ❚Figure 1❚. GeneScan analysis
detected a monoallelic T-cell population that involved the Vgamma-I family in 3 patients (cases 1, 3, and 4). Two TCR
gamma gene rearrangements that involved the V-gamma-II
and V-gamma-IV families were detected in case 2, and 1
TCR gamma gene rearrangement that involved the Vgamma-II family was detected in case 7. Cases 5 and 6
contained monoclonal TCR gamma gene rearrangements
detected by PCR coupled with GC clamped denaturing
gradient gel electrophoresis, as reported previously.9
Discussion
HSTCL is an uncommon type of peripheral T-cell
lymphoma characterized by hepatosplenomegaly without
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Am J Clin Pathol 2001;116:410-419
significant lymphadenopathy, with clinically significant
cytopenias, and with an aggressive clinical course.1,2,4,5 A
characteristic feature of HSTCL is the preferential localization
of the neoplastic cells within the sinusoids of the liver and
spleen.1,5 HSTCL also commonly involves the bone marrow,
and different patterns of involvement have been reported,
including exclusively sinusoidal,1,2,4,5,8,9,14,15 interstitial,7,16,17
and mixed sinusoidal and interstitial.18,19 The cytologic
features of the previously reported cases have varied from
case to case, although a monomorphic population is usually
described for an individual tumor. The neoplastic cells have
been reported to be small, 16 small to medium, 4,15,17,20
medium,1,2,8,9,15,18,21 or medium to large cells.7,18,19
We present the clinicopathologic features of 8 cases of
HSTCL involving bone marrow and emphasize the changes
that occur during progression of disease. The initial diagnostic bone marrow specimens were available for review in 7
© American Society of Clinical Pathologists
Hematopathology / ORIGINAL ARTICLE
❚Table 2❚
Bone Marrow Morphologic Features
Case No./Bone
Marrow Biopsy
Cellularity (%)
Tumor Load (%)*
Infiltration†
Major Cell Morphologic Features
(Size/Chromatin/Nucleolus)
1
Diagnosis
4 mo
90
90
60
95
I/S
I/S
Medium/granular/inconspicuous
Medium/open/large
Diagnosis
10 mo
70
35
14
62
I/S
I/S
Medium/open/small
Medium/open/small
Diagnosis
1 mo
2 mo
6 mo
75
75
85
70
20
20
30
30
I/S
I/S
I/S
I/S
Small/coarse/inconspicuous
Small/coarse/inconspicuous
Large/coarse and open/small
Large/coarse and open/small
Diagnosis
12 mo
NA
95
NA
92
NA
I/S
NA
Medium/open/small
Diagnosis
23 mo
60
90
28
80
I/S
I/S
Small/coarse/inconspicuous
Medium/open/small
Diagnosis
1 mo
95
95
30
30
I/S
I/S
Small/coarse/inconspicuous
Small/coarse/inconspicuous
Diagnosis
1 mo
75
60
5
5
I/S
I/S
Small/coarse/inconspicuous
Small/coarse/inconspicuous
Diagnosis
2 mo
60
50
20
25
I/S
I/S
Medium/open/small
Medium/open/small
2
3
4
5
6
7
8
I/S, interstitial/sinusoidal.
* Based on aspirate smears.
† Predominant pattern in bold.
of 8 cases. The core biopsy specimens were hypercellular with
a subtle infiltrate of atypical cells. The pattern of infiltration
was predominantly sinusoidal in 6 cases and predominantly
❚Image 4❚ (Case 1) Small, medium, and large atypical cells
were identified in all aspirate smears. The larger cells had a
blastic appearance (Wright-Giemsa, original magnification
×1,000).
© American Society of Clinical Pathologists
interstitial in 1 case. However, interstitial infiltrates were
identified in cases with a predominantly sinusoidal pattern,
and a sinusoidal infiltrate was identified in a case with a
predominantly interstitial pattern. Immunohistochemical
stains for T-cell antigens accentuated both the sinusoidal and
interstitial components. Similarly, immunohistochemical
stain for factor VIII–related antigen accentuated the sinusoidal component. The discrepancy between the incidence
of interstitial bone marrow involvement reported in the literature and our cases may be due to the observation that interstitial infiltration is often subtle and difficult to recognize
without immunohistochemical stains early in the disease
course. Thus, interstitial bone marrow infiltration by HSTCL
may be more common than is currently reported in the literature. Interestingly, the neoplastic cells in HSTCL had a
tendency to percolate between normal hematopoietic cells.
In the initial diagnostic aspirate smears, the infiltrate
was composed of atypical small to medium lymphoid cells.
Predominantly small cells with occasional scattered
medium-sized cells were seen in 4 cases, and predominantly
medium-sized cells were seen in 3 cases. The small cells
possessed nuclei with irregular contours and coarse chromatin. The medium-sized cells resembled blasts, with more
open chromatin and frequently small but conspicuous
nucleoli. However, in all cases, aspirate smears at the time of
Am J Clin Pathol 2001;116:410-419
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Vega et al / HEPATOSPLENIC T-CELL LYMPHOMA IN BONE MARROW
A
B
❚Image 5❚ (Case 4) Hepatosplenic gamma/delta T-cell lymphoma involving skin. A, The neoplastic cells showed prominent
epidermotropism (H&E, original magnification ×100). B, Neoplastic cells were also seen within some dermal blood vessels
(H&E, original magnification ×400).
diagnosis had at least a small population of medium-sized
cells that resembled blasts, some with fine cytoplasmic
granules.
We observed a change in the histologic and cytologic
features of HSTCL over the disease course. With progression, the pattern in bone marrow biopsy specimens became
increasingly interstitial, and the neoplastic cells became
larger and blastic. In aspirate smears, the proportion of
blastic cells increased. Similarly, the number of mitotic
figures increased with time. Blastic transformation of
HSTCL has been described in some reports, but almost
always during the terminal phase of disease.7,8,14,16,20 In our
cases, a subpopulation of blastic cells was present in the
initial diagnostic specimens. These cells were identified
more easily in the aspirate smears than in the core biopsy
specimens. Although the increasing number of blastic cells
raises the possibility of a secondary acute leukemia, the
immunophenotype of the neoplastic cells was unchanged or
very similar over time.
The core biopsy sections in all cases contained conspicuous blood vessels that appeared branched and tortuous.
These vessels bear some resemblance to the vessels that are
A
B
❚Image 6❚ (Case 3) Autopsy examination revealed extensive intravascular involvement by lymphoma throughout the body,
including brain (A, H&E, original magnification ×400) and lung (B, H&E, original magnification ×200).
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© American Society of Clinical Pathologists
Hematopathology / ORIGINAL ARTICLE
❚Table 3❚
Immunophenotypic Findings
Case No.
CD2
CD3
CD4
CD5
CD7
CD8
CD16
CD56
CD57
CD19
CD20
CD25
CD34
CD52
CD38
TCR gamma/delta
TCR alpha/beta
TdT
TIA-1†
1
2
3
4
5
6
7
8
+
+
–
–
+
–
–
+
–
–
–
ND
–
–
+
+
–
–
+
+
+
–
+
–
–
+
+
–
–
–
–
–
–
+
+
–
–
+
+
+
–
–
+
+
ND
+*
ND
–
–
ND
–
+
ND
+
–
–
+
+
+
–
–
+
+
ND
+
ND
–
–
–
–
+
+
+
–
–
+
+
+
–
–
+
–
+
+
–
–
–
–
ND
ND
+
+
–
–
+
+
+
–
–
+
–
+
+
–
–
–
ND
ND
ND
ND
ND
ND
ND
+
+
+
–
–
+
–
–
–
–
–
–
–
–
ND
+
+
–
ND
ND
+
+
–
–
+
–
–
+
–
–
–
ND
ND
ND
ND
+
–
–
+
ND, not determined; TCR, T-cell receptor; TdT, terminal deoxynucleotidyl transferase.
* Positive by flow cytometric analysis and negative by immunohistochemical analysis.
† By immunohistochemical analysis.
seen in solid tumors and in the bone marrow of patients with
chronic myeloproliferative disorders.22
The immunophenotypic findings in our cases are similar
to those previously reported by other investigators.2,4,5,7 All
cases expressed a mature, aberrant, gamma/delta T-cell
immunophenotype. Seven of 8 cases also expressed the
natural killer (NK) cell–associated antigen CD56, and 3 of 6
cases tested coexpressed CD16. Six cases were negative for
both CD4 and CD8, the most common immunophenotype
observed in HSTCL.2,4,5 However, 2 cases expressed CD8.
Only 1 case was positive for CD5. These findings are consistent with previous reports. 4,5,7 Seven of 7 cases tested
expressed the cytotoxic granule–associated protein TIA-1, a
granule membrane protein whose expression is restricted to
cytotoxic cells, regardless of their activation status.23,24 TIA1 expression has been reported frequently in the cases of
gamma/delta T-cell lymphoma regardless of the site of localization, ie, hepatosplenic or nonhepatosplenic.5,6,25
The differential diagnosis of HSTCL includes other
lymphoproliferative processes that may show sinusoidal
bone marrow involvement, such as intravascular lymphoma
and splenic marginal zone B-cell lymphoma.26-28 The B-cell
lineage of the neoplastic cells should easily distinguish these
processes from HSTCL. Rare cases of intravascular
lymphoma have been reported to be of T-cell lineage.26,29-36
Most of these cases have not been evaluated for expression
of the alpha/beta or gamma/delta TCR. It is conceivable that
some intravascular T-cell lymphomas previously reported
were examples of HSTCL. Moreover, an autopsy performed
© American Society of Clinical Pathologists
on one of our patients demonstrated malignant cells within
small to medium-sized blood vessels in all organs, with relatively little tumor formation, resembling intravascular
lymphoma.
The differential diagnosis of HSTCL also includes large
granular lymphocyte leukemia (LGL), aggressive NK cell
leukemia/lymphoma, lymphoblastic lymphoma/leukemia,
and myelodysplastic syndrome. Patients with LGL are
usually older adults who often have an autoimmune disease
such as rheumatoid arthritis. Two subsets of LGL have been
reported, one of T-cell lineage (CD3+, CD5+[dim], TCR
alpha/beta positive, CD56–) and the other of NK-cell lineage
(CD3–, TCR alpha/beta negative, CD57+/–).37 The clinical
setting, immunophenotype, and the presence of large intracytoplasmic granules help to distinguish LGL from HSTCL.
Aggressive NK-cell leukemia/lymphoma often involves the
liver and spleen, may have blastic cytologic features, and
may be difficult to distinguish from HSTCL. Its clinical
course is usually fulminant, with the patients dying shortly
after diagnosis of multiorgan failure.38 The neoplastic cells in
aggressive NK-cell leukemia/lymphoma show cytoplasmic
azurophilic granules. Although they are immunophenotypically similar to HSTCL (CD2+, CD56+, CD16+), they
express all cytotoxic protein markers (granzyme B and
perforin) and lack surface CD3 and TCR. In addition, the
TCR genes are in the germline configuration.38 Precursor Tcell lymphoblastic lymphoma/leukemia also shares some of
the clinicopathologic features of HSTCL. It typically occurs in
older children and adolescents. The malignant cells are blasts
Am J Clin Pathol 2001;116:410-419
417
Vega et al / HEPATOSPLENIC T-CELL LYMPHOMA IN BONE MARROW
aspirate smears may allow recognition of HSTCL early in
the disease course.
Size in Base Pairs
*
A
SS SS SS
SS
SS
SS
SS SS
From the Department of Hematopathology, University of Texas
M.D. Anderson Cancer Center, Houston.
*
*
B
SS SS SS
SS SS SS
*
SS
SS
SS
SS
SS SS
SS
SS
SS SS
C
V-gamma-I
V-gamma-III
V-gamma-II
V-gamma-IV
❚Figure 1❚ T-cell receptor (TCR) gamma chain gene
rearrangements were identified by high resolution GeneScan
(TAMRA-500, PE/Applied Biosystems, Foster City, CA)
analysis. A, Case 3 showed a monoallelic T-cell population
that involved the V-gamma-I family (red). B, Case 2 displayed
two TCR gamma chain gene rearrangements that involved
the V-gamma-II (blue) and V-gamma-IV (green) families. C,
Negative control. *, clonal peaks detected by GeneScan; SS,
internal size standard.
of T-cell lineage that often involve bone marrow.39 Precursor
T-cell lymphoblastic lymphoma can be distinguished from
HSTCL by the presence of TdT. Virtually all lymphoblastic
malignant neoplasms express TdT, while HSTCLs are TdT
negative. The presence of cytopenias and increased numbers
of blasts in the bone marrow raises the possibility of a
myelodysplastic syndrome, such as refractory anemia with
excess blasts or refractory anemia with excess blasts in transformation. Cytochemical stains for myeloperoxidase and
nonspecific esterase are negative in HSTCL but positive in
myelodysplastic syndromes and acute myeloid leukemia.
A useful feature to recognize HSTCL in bone marrow is
the apparent morphologic discordance between bone marrow
core biopsy sections and aspirate smears. The neoplastic
cells appear less blastic in biopsy sections than in aspirate
smears. In addition, the pathologic findings in HSTCL
evolve over the disease course. In biopsy sections, the pattern
of infiltration evolves from predominantly sinusoidal to
predominantly interstitial. In aspirate smears, the percentage
of larger cells and blasts increases. These observations
suggest that the histologic differences between cases
reported in the literature may, in part, reflect disease progression. The combination of a sinusoidal pattern in bone
marrow biopsy sections and blastic cytologic features in
418
Am J Clin Pathol 2001;116:410-419
Dr Vega is a postdoctoral fellow at the University of Texas
M.D. Anderson Cancer Center. He is supported by a grant from
“Fundacion Pedro Barrie de la Maza,” Galicia, Spain.
Address reprint requests to Dr Abruzzo: Dept of
Hematopathology, Box 72, University of Texas M.D. Anderson
Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030.
Acknowledgments: We thank Judith Brody, MD, North Shore
University Hospital, Manhasset, New York, for providing
additional materials.
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