Sweet syndrome (SS), also known as acute neutrophilic dermatosis, is a disorder characterized by painful erythematous plaques. The classic pathological description of these lesions is a neutrophilic infiltrate to the dermis, however lymphocytic infiltrates and infiltrates to the adipose tissue (panniculitis) have also been described (Vignon-Pennamen et al, 2006; Guhl & Garcia-Diez, 2008). Approximately 25% of cases are associated with an underlying malignant or pre-malignant disorder, most commonly acute myeloid leukaemia (AML) or myelodysplastic syndrome (MDS) (Hospach et al, 2009). Fanconi anaemia (FA) is a genetic disease characterized by chromosomal fragility and an increased risk of haematopoietic disorders including MDS and AML (Alter, 2003). SS in the setting of FA has been reported in five cases in the literature (Baron et al, 1989; McDermott et al, 2001; Chatham-Stephens et al, 2008). We describe seven patients with FA and SS and report a more frequent association than is seen in other premalignant conditions. We also detail a more complex syndrome that is associated with extracutaneous manifestations of SS and with progression of haematological disease. A retrospective chart review was conducted of patients with FA and SS diagnosed between 2000 and 2010 at three institutions. Information was collected on the presentation of SS, haematological disease status, and relevant clinical and pathological data. Haematological disease was characterized based on the WHO MDS classification scheme (Vardiman et al, 2009). In cases where tissue specimens were available, the pathology was reviewed by a central pathologist. Cases were reviewed with the approval of the institutional review board at Memorial Sloan-Kettering Cancer Center (MSKCC). We report seven cases of SS in patients with FA diagnosed between 2000 and 2010 (Table I) including one previously described patient (Chatham-Stephens et al, 2008). The incidence of SS in FA at one institution (MSKCC) was estimated at 12%. Patients were diagnosed with FA at ages 5–16 years (mean, 11 years) but were diagnosed with SS at an older age, ranging from 17 to 36 years (mean, 26 years). All patients exhibited painful erythematous nodular skin lesions (Fig 1A). In addition to cutaneous findings, four patients had lung lesions (Fig 1B) and one patient had a bone lesion. Lesions were often initially thought to be of infectious origin. Diagnostic testing for bacteria, viral, or fungal causes was negative in all cases. None of the lesions responded to antibiotics. Clinical and Pathological manifestations of Sweet syndrome in patients with Fanconi anaemia. (A) Upper panel: characteristic nodular skin lesion. Middle panel: skin biopsy at 2× demonstrating neutrophilic infiltrate to superficial and deep dermal tissue. Lower panel: skin biopsy at 60× showing dense neutrophilic infiltrate with histiocytes. (B) Upper panel: CT chest with diffuse bilateral infiltrates. Middle panel: lung biopsy at 2× showing pulmonary nodule with focal consolidation. Lower panel: lung biopsy at 60× demonstrating alveolar macrophages with interstitial focal neutrophilic infiltrate. Skin biopsies were obtained in six of seven patients. A neutrophilic infiltrate to the dermis or subcutaneous adipose tissue was described in five of six cases. In one case the dermal infiltrate was composed mostly of lymphocytes. Lung biopsies were obtained in all four cases with pulmonary involvement. Specimens were found to have infiltrating neutrophils in two of four cases. Pathology reports on the remaining two cases describe non-specific inflammation. Slides in these cases were not available for further review. Of note, four of six patients who underwent skin biopsy had significant complications from poor wound healing including one patient who required skin grafting. Six of seven patients exhibited progression of haematological disease around the time of presentation of SS. Four patients progressed from MDS to AML, one patient from aplasia to MDS, and one patient from MDS-refractory anaemia to MDS-refractory anaemia with excess blasts. Patients treated with steroids had a partial or complete, but often transient, response. Five of seven patients subsequently underwent haematopoietic stem cell transplantation. In all five cases lesions resolved with the conditioning regimen received prior to transplant. There were no cases of SS relapse after transplant. This report represents the largest cohort of patients described with SS and FA and gives an opportunity to evaluate the unique characteristics of this syndrome in the FA host. The incidence of SS in FA may be markedly higher than the incidence of SS in other haematological disorders. Practitioners caring for patients with FA should have an increased index of suspicion for SS in any patient with skin lesions that do not respond to antibiotic treatment. Additionally, any patient with SS and haematological abnormalities or skeletal abnormalities should be tested for FA. The complication of poor wound healing was significant in this cohort and has not been previously reported. We therefore recommend that, when possible, patients with FA and suspected SS should proceed to steroid treatment without skin biopsy. Our patients had a high incidence of extracutaneous lesions. Extracutaneous manifestations of SS are considered rare but have been reported in bone, lung, and gastrointestinal tract (Baron et al, 1989; Chatham-Stephens et al, 2008). Patients diagnosed with cutaneous SS should be evaluated for other sites of disease. Conversely, as extracutaneous manifestations may precede skin lesions, clinicians should have an increased suspicion for SS in FA patients with inflammatory lesions at any site with no infectious aetiology. The onset of SS was associated with progression of haematological disease in six of seven patients. The onset of SS in patients with FA should prompt clinicians to investigate for haematological disease progression including bone marrow evaluation and proceed to treatment of the underlying haematological disease with allogeneic haematopoietic stem cell transplantation as indicated. While the aetiology of SS is not completely understood, it has been postulated to be due to neutrophil dysfunction in the setting of malignancy (Buck et al, 2008). Elevations in cytokines, such as granulocyte colony-stimulating factor, granulocyte-macrophage colony-stimulating factor, interleukin-6, and tumour necrosis factor (TNF)-alpha may lead to the maturation and/or trafficking of neutrophilic precursors in the dermis. There is evidence to suggest that FA patients have elevated expression of TNF-alpha (Briot et al, 2008), perhaps increasing their susceptibility to this 'systemic' syndrome of skin, extracutaneous and haematological manifestations. An investigation into cytokine levels in FA patients with and without SS would be of interest to help further our understanding of this phenomenon. In summary, SS appears to be a relevant entity in FA patients. Rather than a dermatosis, SS in this host is most probably a systemic syndrome associated with or triggered by haematological disease progression, and should be investigated at the clinical level. Moreover, efforts should also be undertaken to understand the pathophysiology of this syndrome, particularly in the FA host.
PNL2 is a novel monoclonal antibody, which has recently been introduced as an immunohistochemical reagent to stain melanocyte and tumors derived thereof. In the present study, we analyzed the immunoreactivity of this mAb in various normal tissues, melanocytic nevi, primary and metastatic melanoma, nonmelanocytic tumors, including histologic mimickers of melanoma as well as angiomyolipoma, and multiple cell lines derived from different tumors types. We used several tissue microarray panels as well as selected conventional sections from tissue blocks. For metastatic melanoma, immunoreactivity for PNL2 was compared with A103 (Melan-A/MART-1), T311 (tyrosinase), HMB45 (gp100), and D5 (MITF). Positive staining with PNL2 was found in normal melanocytes and neutrophils, but no other normal cell type. Among melanocytic lesions, both benign nevi as well as primary malignant melanomas, especially epithelioid variants thereof, were commonly immunopositive. Only 1 of 13 desmoplastic melanomas reacted with PNL2. PNL2 showed high sensitivity for metastatic melanoma (87%). In comparison, 82% of metastatic melanomas were positive for A103, 76% for HMB45, 92% for T311, and 84% for D5. The combined use of all five reagents minimized the number of immunonegative cases. None of the selected nonmelanocytic tumors (carcinomas or soft tissue neoplasms) was positive for PNL2 in this series except for angiomyolipomas and chronic myeloid leukemias and 1 single case of a malignant peripheral nerve sheath tumor with heterologous differentiation (malignant Triton tumor). Despite its reactivity with neutrophils, PNL2 appears to be a valuable supplementary reagent for the diagnosis of melanocytic tumors.
We describe the case of a patient treated with 2-chloro-2'-deoxyadenosine, CdA or Cladribine for hairy cell leukemia who subsequently developed an Epstein Barr virus (EBV)-positive polymorphous large B-cell lymphoma (p-LBCL). The time interval between Cladribine therapy and development of p-BCL was 11 months and morphologically resembled an EBV-positive post transplant lymphoproliferative disorder (PTLD). Molecular genetic studies for EBV-clonality by Southern blot hybridization showed a clonal population of infected cells, implying that this was an EBV induced lesion. The chronology of events suggest that Cladribine, a purine analog which has been previously described to induce long-lasting immunodeficiency, can, in some cases, weaken the host defense mechanism to a level at which an innocuous EBV infection may transform the normal lymphoid cells into an aggressive neoplasm. Unlike most methotrexate-related lymphoproliferative disorders (LPDs), which undergo spontaneous remission after discontinuation of therapy, LPDs secondary to purine analogs often fails to resolve after discontinuation of therapy and requires additional therapy. Our patient was treated with rituximab following the diagnosis of p-LBCL, with the goal of improving the pancytopenia to permit chemotherapy. However, the patient failed to show any dramatic improvements in counts, developed systemic symptoms and progressive ascites. He expired 3 weeks after a second dose of rituximab. Cladribine is a potent immunosuppressive agent and should be included with the list of immunosuppressive agents that may be associated with EBV-related B-cell lymphoproliferative disorders.
Challenges in diagnosing lymphoid neoplasms include their complex heterogeneity and the fact that approximately 40 or more diseases exist. Immunophenotyping and molecular diagnostics have made important contributions to precise and accurate diagnoses. Strong interactions with clinical colleagues and meticulous attention at the microscope by expert hematopathologists are important in making a correct diagnosis. Awareness of the literature and interactions with research colleagues, including clinical, basic, and translational scientists, have expanded understanding of these complex diseases, providing prognostic information that can ultimately assist in appropriate clinical management of patients or development of new targeted therapies. This article reviews recent published immunophenotypic diagnostic and biomarker studies, discusses molecular diagnostic expression profiling studies of the more common entities encountered in daily clinical practice, and references published summaries from the combined Society of Hematopathology and European Association for Haematopathology Workshops. A precise lymphoma diagnosis therefore involves integration of clinical information, morphologic architectural and cytologic patterns, immunohistochemistry, cytogenetics, and molecular biology, to ultimately allow identification of specific diseases, thereby implying prognostic significance and potential therapeutic targets.
Patients with mantle cell lymphoma (MCL) and follicular lymphoma treated with bortezomib have consistent response rates of 30–50% across several clinical trials, suggesting a common tumour biology that may predict response. It remains unknown which processes affected by proteasome inhibitors (PI) are most important in their activity in non-Hodgkin Lymphoma (NHL). Leading theories include inhibition of the cell cycle, nuclear factor κB (NFKB1; NF-κB) signalling, angiogenesis and decreased degradation of anti-apoptotic proteins. Between June 2001 and December 2006, 103 patients enrolled in a multicentre Cancer Therapy Evaluation Program-sponsored Phase II trial and were treated with single-agent bortezomib. Eligibility criteria included: (i) confirmed indolent NHL or MCL, (ii) <3 prior cytotoxic treatment regimens, and (iii) adequate organ reserve (O'Connor et al, 2005; Gerecitano et al, 2009). Tissue microarrays (TMA) were stained for a panel of targets selected for their possible prognostic associations with NHL or mechanisms of action (MOA) of PI (Table S1). We correlated outcome with pre-treatment tumour protein expression patterns in this unique patient population. Tissue microarrays were constructed from 55 pre-treatment tissue blocks as previously published (Koreishi, 2010). Stains for CDKN1A (p21), CDKN1B (p27), BIRC5 (Survivin), TP53 (p53), BCL2, MCL1, CFLAR (c-FLIP), Caspase, VCAM1, REL/RELA (p65), PSMB1 (proteasome subunit β1), PSMA5 (proteasome subunit α5), TOP2A(TOPOα), MIB1/MKI67 (Ki67), CCND1 (cyclin D1), MUM1, BCL6 and CTAG1B (NYEso) were graded by two independent pathologists, and a consensus grade was determined for each marker. Cases were considered positive if >20% of cells showed staining. In cases of discrepancy, the higher value was reported. Stains were also graded on a scale from 0 to 4, representing the proportion of cells per high power field. Nuclear RELA was estimated using continuous percentages, and then separated into quartiles for analysis. In those cases where the diagnostic samples did not run through the entire TMA block, shavings from the initial block were graded separately. Fisher's exact test was used to assess the association between response rates [progressive disease (PD) versus complete response (CR)/partial response (PR)/stable disease (SD), CR/PR versus SD/PD] and the expression of each marker. Progression-free survival (PFS) was defined from the start of treatment to the date of death or progression, whichever occurred first. Patients were censored at their last date of follow-up if they were alive and progression-free. For patients who responded to therapy (CR/PR), duration of response (DOR) was calculated from the date of the best response to the date of progression, and patients who remained progression-free at the last follow-up were censored. None of the patients included in this analysis died prior to disease progression. The Log-rank test or permutation log-rank test was used to compare PFS and DOR between levels of stain expression. Multiple comparison adjustment was not applied considering the exploratory nature of the study. All tests were completed in sas 9.2 (SAS Institute, Inc., Cary, NC, USA) and r version 2.9.2 (http://www.r-project.org/). Demographic and response/survival information for patients included in this analysis (n = 55) reflect the total population (n = 103, Table 1) (Gerecitano et al, 2009; O'Connor et al, 2010). Two proteins showed significant association with response: High expression (50–75%) of MCL1 conferred a decreased chance of achieving SD or better compared with 25–50% or 0–25% expression of MCL (54%, 100% and 73%, respectively P = 0·044). Any expression of BCL6 decreased the chance of achieving SD or better (42% vs. 77%, P = 0·034). Two markers correlated with PFS: Decreased CDKN1B correlated with lower PFS (log-rank test P = 0·047). Patients with zero expression of CDKN1B (n = 2) progressed within 1.4 months (1-year PFS = 0), whereas 1-year PFS of other patients with expression level of 0–25%, 25–50% and 50–75% were 43% [95% confidence interval (CI): 18–66%], 20% (95%CI: 5–42%), and 39% (95%CI: 16–61%), respectively. Patients with zero expression of CFLAR (n = 31) had better PFS compared to patients with 0–25% and 25–50% expression of CFLAR: 1-year PFS was 37% (95%CI: 18–50%), 29% (95%CI: 4–61%), and 0% (95%CI: NA-NA) respectively, log-rank test P = 0·004 (Fig 1). The median time to progression for the entire sample was 5.2 (95%CI: 3.2–10.1) months. Two of these proteins are involved with distinct apoptotic pathways. MCL1 is an antiapoptotic BCL2 family member that correlates with resistance to PI in preclinical studies. This mechanism of resistance may be overcome when bortezomib is combined with small molecule inhibitors of the BCL2 family of proteins (Paoluzzi et al, 2008). In contrast to MCL1, CFLAR decreases death receptor-initiated apoptotic drive. High levels of CFLAR are associated with chemotherapy resistance and poor clinical outcome in other NHLs (Valnet-Rabier et al, 2005). Bortezomib down-regulates the expression of CFLAR in in vitro models (Ri et al, 2008). CDKN1B is a known tumor suppressor gene whose regulation is highly dependent on proteasomal degradation, and increased degradation correlates with poor prognosis in MCL (Chiarle et al, 2000). It is therefore interesting that in both the present study and the PINNACLE trial (Goy et al, 2010) low pretreatment levels of CDKN1B still hold poor prognostic value despite proteasome inhibition. Perhaps some threshold amount of CDKN1B expression is necessary for inhibition of its degradation to impact on prognosis. BCL6 is involved in the pathogenesis of a variety of germinal centre NHL. Bortezomib increases intracellular levels of BCL6 (Cerchietti et al, 2009), and may therefore be ineffective in patients whose tumors express increased levels at baseline. This finding supports ongoing trials evaluating bortezomib in combination with inhibitors of BCL6 (e.g. inhibitors of heat shock protein 90 or histone deacetylase). The use of TMA technology allowed for the staining of many more markers across patients under uniform conditions. Each of the proteins found to correlate with response or survival plays a significant role in the pathogenesis of lymphoma. Limitations of this study include: (i) Different subtypes of NHL are included, (ii) numbers are relatively small due to difficulties in obtaining pathology blocks and (iii) we are not able to conclude whether these markers are specific to patients treated with bortezomib, or are prognostic markers for the diseases studied. The exploratory observations reported will be used in ongoing and future prospective studies to help us identify potential biomarkers of response, which may inform rational combinations of bortezomib with other agents based on insights into molecular pathogenesis. This research was funded by Millennium Pharmaceuticals, The Takeda Oncology Company. J.G. was supported by a Cancer and Leukemia Group B Foundation Clinical Research Award and a Lymphoma Foundation Mortimer J. Lacher, MD Hematology/Oncology Fellowship. The authors would like to acknowledge the advice and consultation of Dr. Carol Portlock during the design of this study. J.G. designed research, analysed and interpreted the data, and wrote the manuscript; S.G. performed research and collected data, J.T-F. performed research and wrote the manuscript, M.A. performed research, S.O., D.L. and C.G. collected and organized data; J.Z and Z.Z. performed statistical analysis and wrote the manuscript, A.M. performed research. G.M. designed research, O.A.O. designed research and wrote the manuscript. J.G. has received research support and served as an uncompensated advisor to Millennium Pharmaceuticals, The Takeda Oncology Company within the past 2 years. OAO has received research support and served as a consultant to Millenium Pharmaceuticals, the Takeda Oncology Company. Alice McDonald and George Mulligan are employees of Millenium Pharmaceuticals, the Takeda Oncology Company. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
