Composite Nodular Lymphocyte-Predominance Hodgkin Disease and [Gamma]-Heavy-Chain Disease: A Case Report and Review of the Literature.
We now report the detailed clinical, pathologic, and laboratory features of a very unusual case of NLPHD with concurrent [Gamma]-heavy-chain disease (GHCD) and provide a literature review of this topic.
REPORT OF A CASE
A 48-year-old white woman was referred to the University of Texas Medical Branch (Galveston, Tex) for evaluation of an 18month history of anemia of unknown cause. Her medical record revealed no prior evidence of hepatosplenomegaly and normal values for serum uric acid, total serum protein, serum protein electrophoresis, and immunoelectrophoresis. She denied symptoms of weakness, fatigue, or reduced exercise tolerance. Indeed, the patient considered herself to be in good physical condition with a normal appetite and stable weight. As a teenager she was prescribed iron supplements for the treatment of anemia, but she discontinued this medication after a few months. As a young adult she was told she had autoimmune hemolytic anemia, but was never treated with immunosuppressive agents. The patient also claimed that several times during her adult life she had been told that she had an enlarged spleen. She denied the use of alcohol but described having a 30-pack-year history of smoking cigarettes. At the age of 15 the patient had a thyroidectomy performed for Graves disease, and she has been taking thyroid replacement ever since. She has been pregnant twice and each pregnancy was uncomplicated. Approximately 3 months before this evaluation she was hospitalized for streptococcal pneumonia.
On physical examination, all of the patient's vital signs were normal. She stood 152 cm tall and weighed 48.3 kg. Examination of her head, ears, eyes, nose, and throat revealed no abnormalities. An old thyroidectomy scar was visible on her neck, but she had no cervical masses. No lymph nodes were palpable in cervical, supraclavicular, axillary, or inguinal regions. Auscultation of her chest revealed inspiratory crackles in both posterior lung fields. A grade II/VI injection murmur, thought to be a heroic murmur, was audible over the precordium. Her spleen was easily palpable 13 cm below the left costal margin, and the splenic edge was palpable at her midabdominal line. The liver was enlarged and extended 10 cm below the right costal margin. No masses were palpated in the abdomen. Computed tomographic scans of the chest, abdomen, and pelvis revealed hepatosplenomegaly and several small retroperitoneal lymph nodes. The patient underwent splenectomy and perisplenic lymph node biopsy. Nine months after removal of her spleen, nephelometry revealed that serum immunoglobulin (Ig) levels (15 g/L IgG, 0.74 g/L IgA, 0.68 g/L IgM) had returned to normal levels, and immunofixation electrophoresis revealed that the monoclonal heavy chain had disappeared.
MATERIALS AND METHODS
Histopathology and Immunohistochemistry
Samples of lymph node and spleen were processed in 10% neutral buffered formalin or B-5 and were embedded in paraffin. Bone marrow biopsy material was acid decalcified prior to formalin fixation. Four-micrometer-thick tissue sections were stained with hematoxylin-eosin. Immunohistochemistry was performed using a Ventana ES automated immunostainer (Ventana Medical Systems Inc, Tucson, Ariz). Antibodies to human pCD3, CD15, CD20, CD30, CD43, CD45, CD45R(A), CD45RO, CD57, epithelial membrane antigen, Epstein-Barr virus, and [Kappa] and [Lambda] light chains were used per the manufacturers' instructions (Dako Corporation, Carpinteria, Calif; Ventana) and detected with a universal biotin-avidin-peroxidase kit (DAB Kit, Ventana), which uses biotinylated anti-mouse/rabbit IgG, streptavidin-horseradish peroxidase, and diaminobenzidine followed by hematoxylin counterstain.
Polymerase Chain Reaction
Polymerase chain reaction (PCR) was performed on crude DNA extracted from deparaffinized tissue sections after overnight proteinase K digestion at 37 [degrees] C. Polymerase chain reaction primers for human [V.sub.H] and [J.sub.H] regions were prepared as previously described by Trainor et al. Each 100-[micro]L PCR reaction contained 50 mmol/L potassium chloride, 2 mmol/L magnesium chloride, 1% Triton X-100, 2.5 traits Taq polymerase (Promega, Madison, Wis), 0.2 mmol/L dNTPs (deoxynucleotide triphosphate), 0.3 [micro]mol/L primers, and 1 [micro]g DNA (EZ Start PCR Mix-In-A-Tube, Molecular Bio-Products, San Diego, Calif). Controls run with the samples included positive control B-cell lymphoma DNA and negative water blank. The cycling conditions were 95 [degrees] C x 2 minutes (hot start) followed by 40 cycles of 95 [degrees] C x 1 minute, 55 [degrees] C x 1 minute, and 72 [degrees] C x 1 minute, followed by a final 72 [degrees] C overnight extension. Following 0.8% agarose/TBE buffer gel electrophoresis, the PCR products were stained with ethidium bromide, and bands were detected by UV illumination. Positive bands representing clonal rearrangements are expected between 100 and 120 base pairs in length.
All routine clinical chemistry tests, including total protein (serum and urine), were performed on a Johnson & Johnson Vitros 950 analyzer (Johnson &
Johnson, Rochester, NY). Serum immunoglobulin levels were evaluated on an Array Protein System 360 nephelometry instrument (Beckman-Coulter, Brea, Calif). Serum protein electrophoresis was performed on a Helena Rep (Helena Laboratories, Beaumont, Tex), and immunofixation electrophoresis was performed using a Paragon electrophoresis system (Beckman-Coulter). All instruments and methods used reagents purchased from the manufacture and were performed according to the manufacturers' instructions.
Histopathology and PCR Analysis
A biopsy of a perisplenic lymph node revealed diffuse effacement by a vaguely nodular lymphocyte-predominant infiltrate with admixed large cells (Figure 1, A). Most of the lymphocytes were small and mature with a low mitotic rate. Admixed within the small lymphocytic infiltrate were scattered large L&H cells with abundant clear cytoplasm and large irregularly folded nuclei with 2 to 4 small nucleoli (Figure 1, B). No classical Reed-Sternberg cells were identified. Inflammatory cells (plasma cells, eosinophils, and neutrophils) were inconspicuous.
Immunoperoxidase stains revealed that the small lymphocytic infiltrate was T-cell predominant (CD45RO, CD43 positive) with residual B-cell aggregates (CD20, CD45RA positive) and many scattered large CD20/CD45-positive L&H-type B cells (Figure 1, C), which were weakly positive for epithelial membrane antigen and CD30 but negative for CD15, [Gamma] heavy chain, [Kappa] light chain, and [Lambda] light chain. Increased numbers of IgG-positive, light-chain-negative plasmacytoid cells were noted in the internodular regions, while increased numbers of CD57-positive T cells were noted within the nodules. No Epstein-Barr virus latent membrane protein-1 (LMP1)-positive cells were detected. Polymerase chain reaction for immunoglobulin gene ([V.sub.H]-[J.sub.H]) rearrangement detected only oligoclonal bands consistent with oligoclonal B cells. A diagnosis of Hodgkin disease, nodular lymphocyte-predominance subtype was made and confirmed by an external hematopathology consultant.
Sections of spleen (Figure 1, E) revealed a vaguely nodular white pulp lymphoid infiltrate composed of an admixture of mature small lymphocytes, scattered large cells with abundant cytoplasm, and a few histiocytic aggregates. The white pulp infiltrates closely resembled the lymph node infiltrate. Similar to the lymph node, the splenic red pulp contained numerous IgG-positive, [Kappa]/[Lambda]negative plasmacytoid cells (Figure 1, F through H).
A bone marrow biopsy revealed a patchy lymphoid infiltrate (Figure 1, D) composed predominantly of small mature T cells (CD45RO positive) with admixed large B cells (CD20, weakly CD30 positive) and a few epithelioid histiocytic aggregates. Iron stains revealed increased storage iron with decreased sideroblasts--changes consistent with anemia of chronic disease.
Hematology and Protein Immunoelectrophoresis
A blood count showed a hemoglobin level of 91 g/L (reference range [rr] 115-155 g/L); hematocrit, 0.272 (rr 0.34-0.45); erythrocytes, 3.27 x [10.sup.12]/L (rr 3.9-4.95 x [10.sup.12]/ L); mean corpuscular volume, 83.2 fL (rr 82-97 fL); red cell distribution width, 17.3% (rr 11.8%-14.1%); reticulocytes, 2.5% (rr 1.4%-2.8%); platelets, 114 x [10.sup.9]/L (rr 150400 x [10.sup.9]/L); and leukocytes, 4.1 x [10.sup.9]/L (rr 4.5-10.5 x [10.sup.9]/L). These results were consistent with normocytic (nonhemolytic) anemia, thrombocytopenia, and leukopenia. A leukocyte differential count revealed mild absolute neutropenia with left shift, mild monocytopenia, and mild eosinophilia (44% neutrophils, 13% neutrophilic bands, 30% mature lymphocytes, 8% eosinophils, 4% monocytes, and 1% atypical lymphocytes). Iron studies (increased ferritin, 520 [micro]g/L [rr 11-307 [micro]g/L]; decreased serum iron, 4.48 [micro]mol/L [rr 8.95-28.64 [micro]mol/L]; decreased total ironbinding capacity, 33.83 [micro]mol/L [rr 42.96-73.39 [micro]mol/L]; and decreased iron saturation, 13% [rr 20%-50%]) were consistent with anemia of chronic disease.
Total serum protein measured 67 g/L (rr 60-80 g/L). Serum protein electrophoresis revealed a normal albumin level of 37 g/L (rr 30-48 g/L); normal [[Alpha.sub.1]]-globulin, 2 g/L (rr 2-4 g/L); normal [[Alpha.sub.2]]-globulin, 6 g/L (rr 6-12 g/L); increased [Beta]-globulin, 20 g/L (rr 7-14 g/L); and decreased [Gamma]-globulin, 3 g/L (rr 10-18 g/L). An "M" protein spike, visible in the beta region on electrophoresis, measured 20 g/L by densitometry (Figure 2, A). Immunofixation demonstrated what was initially thought to be increased IgG (36 g/L by nephelometry; rr 6.39-13.49 g/L). More careful study showed this protein lacked [Kappa] and [Lambda] light chains, observations consistent with GHCD (Figure 2, B). The [Gamma] heavy chain was found to be of the IgG1 subclass. Further studies revealed decreased IgA (0.49 g/L; rr 0.69-3.09 g/ L) and IgM (0.40 g/L; rr 0.53-3.35 g/L). Additional chemistry abnormalities included increased uric acid (0.6 [micro]mol/L; rr 0.006-0.065 [micro]mol/L) and increased [[Beta.sub.2]]-microglobulin (10.6 mg/L; rr 1.1-2.4 mg/L). Tests of blood coagulation, renal function, and hepatic function were all within normal limits. Serum calcium and phosphorus before and after identification of the GHCD were normal. Repeat serum protein electrophoresis 9 months following splenectomy was normal with no evidence of an M protein spike.
Nodular lymphocyte-predominance Hodgkin disease is an uncommon form of Hodgkin disease that most often presents as asymptomatic lymphadenopathy and follows a relatively indolent course. Unlike the typical Reed-Sternberg cells of so-called classic Hodgkin disease, the L&H Reed-Sternberg cells characteristic of NLPHD are B cells by virtue of their expression of the B-cell-restricted antigen CD20. However, given their relative paucity in tissue sections, it has been difficult to confirm that these B cells are monoclonal by Southern blot immunoglobulin gene rearrangement analysis. Using the more sensitive technique of single-cell immunoglobulin gene PCR, investigators have recently confirmed that indeed the abnormal ReedSternberg-like cells of NLPHD are monoclonal B cells.[7-9]
[Gamma]-Heavy-chain disease, first described by Franklin et al and Osserman and Takatsuki, is a rare disease that presents in adults (median age mid-60s) with fever, malaise, fatigue, palatal edema, lymphadenopathy, and splenomegaly. Skeletal lesions are uncommon. The diagnosis is confirmed by serum and/or protein immunoelectrophoresis, which reveals an increased amount of immunoglobulin [Gamma] heavy chain not associated with light chain. Peripheral blood findings are nonspecific but may include anemia, leukopenia, thrombocytopenia, and eosinophilia. Autoimmune hemolytic anemia is common. The marrow findings are also nonspecific but may include lymphocytosis, plasmacytosis, and eosinophilia, while amyloid deposition is uncommon. Changes in lymph node and spleen are also nonspecific but may include lymphoid infiltrates and granulomas. The clinical course of GHCD is highly variable, with survival times ranging from a few months to 20 years. If therapy is required, glucocorticoids and systemic chemotherapy may be effective. Therapy in some cases may induce a complete remission, including disappearance of the [Gamma]-heavy-chain spike. However, patients are at risk of infection and progression of disease, including development of plasma cell leukemia.
Wester et al summarized the histopathologic findings of 8 new cases, as well as the 66 previously reported cases of GHCD. Of the 74 total cases, 53 presented with disseminated lymphoproliferative disease, while 21 presented with localized lymphoproliferative disease. Most of the disseminated cases were classified as either "lymphoplasmacytic proliferation" or malignant non-Hodgkin lymphoma. The most common localized presentations included marrow lymphoplasmacytic infiltrates and extramedullary plasmacytoma. Fermand et al reported the clinicopathologic findings of 16 new cases and summarized the findings of the previously reported cases. In agreement with Wester et al, these authors were impressed by the lack of a specific histopathologic pattern in GHCD in contrast to [Alpha]-heavy-chain disease.
While the association of Hodgkin disease with monoclonal gammopathy is rare,[2-6] the association with GHCD is extremely rare. In only 4 cases has the lymphoma associated with GHCD been classified as probable Hodgkin disease. Di Benedetto et al described a 62-year-old white woman who presented with fatigue, weight loss, and left supraclavicular adenopathy. Serum studies revealed a [Gamma] ([Gamma]3)-heavy-chain paraprotein. Lymph node biopsy and staging revealed mixed cellularity Hodgkin disease, stage IIIB. Three years after chemotherapy, the Hodgkin disease was in remission, while the paraprotein persisted. The authors suggested 3 possibilities regarding pathogenesis: (1) 2 unrelated neoplastic processes, (2) [Gamma] heavy chain produced by the Hodgkin cells, or (3) a single (presumably B-cell) neoplastic process leading to 2 subclones, one producing Hodgkin disease and the other producing the GHCD. For a number of reasons, the authors appeared to regard the possibility that the Hodgkin cells produce the [Gamma]heavy chain as the least likely.
Cozzolino et al described a 50-year-old woman with a history of nodular sclerosis Hodgkin disease who presented with GHCD, stage 2B. Despite initial complete remission with radiotherapy 7 years prior to the development of GHCD, her Hodgkin disease relapsed twice before a final remission was induced by MOPP (mechlorethamine, vincristine, procarbazine, prednisone, doxorubicin, bleomycin, vinblastine, and decarbazine) chemotherapy more than 3 years prior to the development of GHCD. These authors suggested that the 2 diseases were likely clonally unrelated, since the expert opinion at that time was that Reed-Sternberg cells were not B cells--an opinion now considered to be incorrect. However, the lack of concurrence of the 2 processes makes it difficult to argue that the processes were related.
Ellman and Bloch described a 76-year-old man with anorexia, weight loss, moderate hepatosplenomegaly, generalized lymphadenopathy, and a [Gamma]-heavy-chain M spike. Lymph node histology revealed a pleomorphic infiltrate with Reed-Sternberg-like cells suspicious for Hodgkin disease. Following chemotherapy, the patient succumbed to bronchopneumonia.
Westin et al reported 3 cases of GHCD, 1 of which was associated with a Hodgkin disease-like process. This 47year-old woman with a history of myasthenia gravis and numerous upper respiratory tract infections presented with fever, hepatosplenomegaly, and lymphadenopathy. Lymph node biopsy was suspicious for Hodgkin disease. A faint [Gamma]-heavy-chain spike was identified in serum and urine. Despite chemotherapy the patient died less than 1 year later. It is striking that the histology depicted in the photomicrograph from this case very closely resembles lymphocyte-predominance Hodgkin disease and that the authors stated that the histology was "morphologically most similar to a Hodgkin's sarcoma but without any definite Reed-Sternberg cells." Indeed, definite Reed-Sternberg cells are absent in NLPHD and instead large L&H cells like those in their figure are seen. It is interesting to speculate that the case described by Westin et al might be similar to the present case.
To our knowledge, an association of GHCD with the nodular lymphocyte-predominant form of Hodgkin disease has not been reported previously. Given the recently confirmed monoclonal B-cell nature of NLPHD, the association with GHCD suggests that the GHCD and the Hodgkin disease in this case might be clonally related. Although we were able to demonstrate [Gamma]-heavy-chain expression in plasma cells in the spleen by immunoperoxi dase staining, we were unable to detect either L&H cell-associated [Gamma] heavy chain by immunoperoxidase staining or clonal immunoglobulin heavy-chain gene rearrangement from the lymph node tissue from this case. Heavychain rearrangements in GHCD are often characterized by deletions in the variable region ([V.sub.H]) and the first constant region domain ([CH.sub.1]), leading to production of abnormal truncated heavy chains that do not associate with light chains. This type of deletion may remove critical [V.sub.H] or [J.sub.H] PCR primer binding sites, thus preventing amplification of the abnormally rearranged heavy-chain gene. The numerous mutations and deletions that have been described within the immunoglobulin heavy-chain locus in Hodgkin cells may also contribute to lack of immunoglobulin locus PCR amplification in Hodgkin disease. Unfortunately, since unfixed tissue was unavailable in this case, we were unable to examine the immunoglobulin rearrangements more carefully by Southern blot.
Perhaps more detailed examination of immunoglobulin rearrangements in cases such as ours and the cases reported by Di Benedetto et al and Westin et al may lead to a better understanding of the possible clonal relationship between Hodgkin disease and composite or sequential "non-Hodgkin" B-cell lymphoproliferative processes such as GHCD.
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Accepted for publication January 9, 2001.
From the Departments of Pathology and Laboratory Medicine (Hematopathology) (Dr Hudnall), Internal Medicine (Hematology-Oncology) (Dr Alperin), and Pathology and Laboratory Medicine (Clinical Chemistry) (Dr Petersen), University of Texas Medical Branch, Galveston, Tex.
Reprints: S. David Hudnall, MD, Department of Pathology and Laboratory Medicine, Division of Hematopathology, University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-0741 (email: firstname.lastname@example.org).
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|Author:||Hudnall, S. David; Alperin, Jack B.; Petersen, John R.|
|Publication:||Archives of Pathology & Laboratory Medicine|
|Date:||Jun 1, 2001|
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