Eosionophilic leukemia: report of a case including autopsy findings

larger series, a p o r t i o n o f t h e s e t u m o r s a r e now t h o u g h t t o be l e s s a g g r e s s i v e and may be distinquished m o r p h o l o g i c a l y f r o m t h e more aggressive tumors. B a s e d on m i c r o s c o p i c features s u c h as m i t o t i c activity, endothelial tufting, papillary formation, a n d s o l i d a r e a s , D o n n e l l and R o s e n have designated t h r e e g r a d e s of h e m a n g i o s a r c o m a . We h a v e r e v i e w e d ii of t h e s e t u m o r s f r o m C . R . T . C . files and compared our experience w i t h t h a t of the l i t e r a t u r e . Of n i n e c a s e s w i t h £ o l l o w u p at the t i m e of writing, the o v e r a l l s u r v i v a l r a t e w a s 55% at 3 y e a r s a n d 27% at 5 y e a r s . We c o n f i r m e d the correlation b e t w e e n the g r a d e of the t u m o r a n d survival rate. The histopathology a n d the d i f f e r e n t i a l diagnosis w i l l be r e v i e w e d . 95 PROSTATIC ACID PHOSPHATASE & PROSTATE SPECIFIC A~ttus~ t~ THE DIAGNOSIS OF METASTATIC CARCINOMA OF UNKNOWN PRIMARY SITE. P.N.Manley, E.R. Weir, Dept. of Pathology, Kingston General Hospital and Queen's University. The typical presentation of carcinoma of the prostate is obstructive uropathy with metastases to the draining lymph nodes and/or axial skeleton. Rarely, there are unusual clinical presentations such as polymyositis and atypical metastatic sites such as the orbit, breast, abdominal viscera, supraclavicular lymph nodes and brain. As patients with prostatic adenocarcinoma experience rapid symptomatic improvement and a prolonged five year survival with hormonal manipulation, it is important to quickly make the correct diagnosis. Prostatic acid phospbatase (PAP) and prostate specific antigen (PSA) are very specific and highly sensitive markers for both benign and malignant prostate epithelial cells. We reviewed the files of our regional cancer clinic to determine if cases of occult prostatic carcinoma were incorrectly classified as carcinoma of unknown primary site (CUP) and to ascertain if PAP and/or PSA immunohistochemistry could diminish the time interval between the initial biopsy of the metastatic site and the diagnosis of prostatic carcinoma. We found 3/100 cases of metastatic prostatic carcinoma in which there was a delay of one to four months in confirming their prostatic origin. All had an unremarkable prostate gland on initial physical examination and two had no evidence of malignancy on initial needle biopsies. 0/46 biopsies of CUP with a follow-up of six months showed PAP or PSA reactivity. We suggest that PSA and/or PAP be used in cases of non-squamous CUP in all males over 50 to expedite the diagnostic management and to ensure that specific hormonal therapy be instituted for prostatic adenocarcinoma. 96

POSITIVE DIRECT ANTIGLOBULIN TESTS IN MYELOMA OCCURRENCE, CHARACTERIZATION & SIGNIFICANCE. B. Dalai, S. Young, K. Burnie & R. Barr, Dept. of Hematology, University Hospital, London, N6A 5A_5. Direct antlglobulin test (DAT) results were analysed from 72 patients with myeloma studied between 1972 and 1984. Nineteen of 38 patients with IgG myeloma had a positive DAT. In contrast, only one of 12 patients with IgA myeloma and one of 13 with light chain myeloma had a positive DAT. Ethereluates of erythrocytes were performed on four IgG myeloma patients and in each the monoclonal immunoglobulin eluted was identical to that in the serum. The association of the positive DAT with erythrocyte antigens and drugs taken by the patients will be discussed. When 6 patients with positive DAT using polyspeciflc anti-human globulin reagentwere tested with ~ different commerclalmonospecific anti-lgG reagents, the results varied from negative to 2+. IgG~ subtype monoclonal protein was present in 7 of i0 patients with IgG myeloma and positive DAT. The significance of this frequency of positive DAT in IgG myeloma patients, and relationship to other hematologic tests will be discussed.

97

DEVELOPMENT OF AN IN VITRO STEMCELL ASSAY FOR PREDICTIVE DRUGTESTING

D.I. Robertson, G. Stuart, A. Wong, P.H.S. Geggie, and O. Siu; Depts. of Pathology, Obstetrics and Gynecology, Medicine and Epidemiology, University of Calgary and Tom Baker Cancer Centre, Calgary, Alberta TZN 2T9 The human tumor stem cell assay (Hamburger, A.W. and Salmon, S.E. (1977) Science 197:461-463) may provide a new source of data to guide clinicians in the chemotherapeutic management of selected oncology patients. Using the soft agar tissue culture technique, we have cultured 43 of 57 CLINICAL BIOCHEMISTRY, VOLUME 17, JUNE 1984

specimens for a cloning success rate of 75%. Tumors of a single histopathologic type showed considerable variation in response to anti-neoplastic drugs, measured as a reduction in the number of tumor colonies compared t o ' t h e control number of colonies. We have also collected tumor colonies for electron microscopy after 14 days incubation and in the case of a melanoma provided ,~rphologic proof that the tumor colonies counted are indeed derived from the single cell suspension of malignant cells. The preliminary results have led to the development of a prospective clinical t r i a l involving patients with carcinoma of the breast, colon, ovary, and endometrium. The in vitro chemosensitivity results will be used to determine subsequent clinical management. The objective of this randomized prospective study w i l l be to determine i f the in vitro chemosensitivity data are predictive of subsequent patient response to various chemotherapeutic agents. This work was supported by the Nat Christie and Kahanoff Foundations. 98 MIGRATION INHIBITION FACTOR (MIF) ASSAY: CORRELATION WITH I ~ U N I T Y IN VIV0. K. RaJaraman, M. MacSween and T. Ghose (Depts. of Microbiology, Medicine and Pathology, Dalhousle University and the Victoria General Hospital, Halifax, N.S. B3H 4H7). Evaluation of cell mediated immunity in cancer patients or in receiplents of allografts is clinically important. Although a number of in vitro methods for the assay of cell mediated immunity are available, their usefulness as predictors of cell mediated immunity in vlvo has been poor, Using the mouse EL4 lymphoma, we have investigated the correlation between the results of MIF assay and the resistance of normal and immunized syngenelc C57BL/6Jmlce and allogenelc BALB/c mice to the growth of this tumor in vlvo. The tumor progressively grew and killed normal syngenelc mice, but did not take in the allogenelc mice or in immunized syngenelc mice. However, the allogenelc tumor progressively grew in cyclosporln A treated or athymic BALB/c mice. Using a homogenate of EL4 cells as the antigen, MIF assay was positive with spleen cells from innnunlzed C57BL/6J mice or from normal BALB/c mice. On the other hand, MIF assay was negative with spleen cells from normal and tumor bearing syngenelc mice or athymlc or cyclosporin A treated BALB/c mice. Thus in this model the results of MIF assay correlate with the status of in vlvo resistance to a syngenelc tumor or to an allograft. 99 AN EVALUATION OF THE AUTOMATED MULTICHANNEL BLOOD COUNT FOR HEMATOLOGIC CASEFINDING ON ELECTIVE HOSPITAL AONISSION. B. McNeely and W. Boyko, Dept. o f Pathology, St. Paul's H o s p i t a l , Vancouver, B. C. V6Z 1Y6 A p r e v i o u s l y defined p o p u l a t i o n o f e l e c t i v e general h o s p i t a l a d u l t i n p a t i e n t s was studied. A blood sample was drawn on admission and the f o l l o w i n g t e s t s were performed: automated seven channel blood count by Coulter Model S p r o v i d i n g hemoglobin, h e m a t o c r i t , WBC, RBC and e r y t h r o c y t e indices, as well as microscopic examination o f the blood f i l m f o r leukocyte d i f f ~ r e n t i a ] count, e r y t h r o c y t e morphology and p l a t e l e t estimate. Examination o f the data revealed that out o f 5088 p a t i e n t s , o n l y 38 showed abnormaJities by microscopic examination w i t h normal values by automated blood count. In only three instances were new diagnoses revealed by microscopic f i n d i n g s alone, none o f which a f f e c t e d the p a t i e n t ' s therapy or course in h o s p i t a l . Analysis o f the data revealed that the automated blood count was 92 per cent as s e n s i t i v e and 99 per cent as s p e c i f i c as microscopic examination o f the blood f i l m f o r hematologic c a s e f i n d i n g on e l e c t i v e h o s p i t a l admission.

HEMATOPATHOLOGY I00 EOSINOPHILIC LEUKEMIA: REPORT OF A CASE INCLUDING AUTOPSY FINDINGS. NAIDOO~ J.A. and IDIKIO, H., DISCIPLINE OF PATHOLOGY, FACULTY OF MEDICINE, M.U.N., ST. JOHN'S, NFLD. AIB 3V6 Eosinophilic leukemia was first described in 1912 although considerable confusion still exists regarding the clinical and pathologic criteria for the diagnosis. There are several reports of cases using differing diagnostic criteria including cytochemlcal and ultrastructural findings, although some have regarded these cases as manifestations of idiopathic hypereoslnophilic syndrome. We present the clinical and pathological findings in a 47year-old male who presented with confusion, aphasia, apraxla and mild hemlparesls of 10 days duration. Investigations

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revealed hemoglobin of 13.2 g% and platelets 183 O00/mm 3. The WBC varied from an initial 22 O00/mm 3 of which 52% were mature eosinophils to 93 O00/mm 3 with 72% mature eosinophils. The bone marrow was hypercellular with 50% eosinophils or eosinophil precursors and gradually evolved into a leukemic picture with increased numbers of myeloblasts and megakaryocytic and erythroid hypoplasia. His drug treatment included hydroxyurea, vincristine and 6-mercaptopurine. He died 18 months after the initial presentation from intractable cardiac failure. The salient findings at autopsy included cardiomegaly, subendocardial fibrosis and mural thrombosis. Microscopy revealed predominantly mature eosinophilic infiltrates In the myocardlum, brain, liver and spleen. The clinical and pathologic findings in this case are in keeping with eosinophilic leukemia. We suggest certain criteria that can help in separating eosinophillc leukemia from idiopathic hypereosinophilic syndrome.

I01

HYPEREOSINOPHILIA AND PLATELET THROMBI IN A PATIENTWITH ANGIOIMMUNOBLASTIC LYMPHADENOPATHY M.Cybulsky & D.J. Bailey, Dept. of Pathology, Toronto General ~oronto, Ontario. MSG IL7 A 30 year old womanwith a 6 week history of cough, fever, pruritic rash and generalized lymphadenopathysuddenly developed l e f t upper extremity paralysis, confusion and obtundation. ACT scan revealed multiple cerebral infarctions. Additional investigations revealed hepatosplenomegaly,marked eosinophilia (l.9xlOlO per L) and thrombocytopenia. Lymph node biopsies carried out before and after the development of neurological findings showed characteristic features of angioimmunoblastic lymphadenopathy (AILD), and surface marker analysis confin,ed the polymorphous composition of the lymphoid proliferation. However,one unusual finding in the lymph nodes was the presence of platelet thrombi in small vessels. In spite of aggressive therapy with high dose corticosteroids the patient deteriorated rapidly and died. An autopsy revealed disseminated candidiasis, intraperitoneal hemorrhage, and AILD involving all lymph nodes, spleen,liver and bone marrow. In addition, there were infarctions of the brain and the myocardium, and these were clearly associated with intravascular platelet thrombi. The association of thrombosis with AILD has been described in three patients who developed a DIC-type syndrome. However, the development of platelet thrombi in AILD, leading to widespread infarction, has not been described. In the present patient the occurrence of widespread platelet thrombi may have been attributable to vascular endothelial damagemediated by eosinophils. Similar thrombi associated with both cerebral and myocardial infarction have been described in patients with hypereosinophilic syndrome. 102 HEMOPHAGOCYTIC S Y N D R O M E DUE TO S Y S T E M I C F U N G A L I N F E C T I O N IN A P A T I E N T W I T H A C U T E L Y M P H O BLASTIC LEUKEMIA. R.Robertson, W.E.N. Corbett. Dept. of P a t h o l o g y , K i n g s t o n G e n e r a l H o s p i t a l & Queen's University. Hemophagocytlc S y n d r o m e is a r e c o g n i z e d complic a t i o n of m a l i g n a n t histiocytosis (MH). MH u s u a l l y arises de n o v o but at l e a s t 17 e a s e s h a v e o c c u r r e d in a c u t e l y m p h o b l a s t i c l e u k e m i a (ALL) a few weeks or months after r e m i s s i o n i n d u c t i o n c h e m o t h e r a p y ( R o s n e r F, and G r u n w a l d H.W. 1983. B l o o d 62, 1 8 | a ) . Hemophagocytic S y n d r o m e occurs also in T ~ lymphoblastic leukemia/lymphoma due to p h a g o c y t i c a c t i v i t y of the n e o p l a s t i c lymphoblasts (Kadin M . E . et al, N E J M 198|, 3 0 4 , 6 4 8 ) . Also recently described is m a s s i v e p r o l i f e r a t i o n of b e n i g n h i s t i o c y t e s causing active phagocytosis of h e m a t o p o i e t i c c e l l s in the bone m a r r o w of i m m u n o s u p p r e s s e d p a t i e n t s ( R i s d a l l R.J. et al, 1979, C a n c e r 44, 9 9 3 ) . V i r a l i n f e c t i o n was d o c u m e n t e d in 75% of cases. The c o n d i t i o n was labelled "Virus Associated Hemophagocytic Syndrome' ( V A H S ) and the i m p o r t a n c e of d i s t i n g u i s h i n g it f r o m MH was e m p h a s i z e d . We p r e s e n t a c a s e of ALL in w h i c h a v i o l e n t h e m o p h a g o c y t i c s y n d r o m e d e v e l o p e d in a s s o c i a t i o n with fatal systemic fungal infection, following successful remission induction chemotherapy. The m o r p h o l o g y , c y t o c h e m i s t r y , ultrastructure, and c e l l t y p i n g d a t a w i l l be p r e s e n t e d , and the f e a t u r e s of this r e a c t i v e h i s t i o e y t e proliferation w i l l be c o n t r a s t e d w i t h t h o s e of MH. 103 TYPE lib VON WILLEERAND'S DISEASE PRESENTING WITH INTERMITTENT SEVERE BLEEDING ASSOCIATED WITH THROMBOCYTOPENIA. A.R. Giles and A. Collins, Department of Pathology,

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Kingston General Hospital, Kingston, Ontario, K7L 2V7 A 6! year old man presented with intermittent severe gastrointestinal bleeding, thrombocytopenla and easy bruising. Family history suggested an inherited coagulation defect. Thrombin clotting time, PT and PTT were normal. The bleeding time was prolonged (gre~ter than 15 minutes) and the platelet count was low (i00 x i0 /I). Assays of F. VIII:RAG, F. VIII:C and ristocetin cofactor were normal. The platelets demonstrated increased ristocetin-induced aggregability, indicating a differential diagnosis of type lib von Willebrand's disease or pseudo-yon Willebrand's disease, a primary platelet disorder. F. VIII vWF multimers were deficient in the plasma, but not in the platelets. Ristocetin-induced aggregation studies using mixtures of washed patient and normal platelets and plasma indicated a plasma abnormality and type lib yon Willebrand's disease was diagnosed. Several asymptomatic family members have since been shown to have von Willebrand's disease and thrombocytopenia. It is important to consider the rarer types of von Willehrand's disease in the differential diagnosis of patients with unusual laboratory findings because F. VIII vWF multimer assays will reveal the exact diagnosis and because the therapy of the different types is significantly different. 104 THROMBOCYTOPENIA WITH FATAL INTRACEREBRAL HEMOPP/4AGE IN INFECTIOUS MONONUCLEOSIS M. Lamba, L.B. Huebsch, D.P. Hill, W.A. McLeish. Department of Pathology, University of Ottawa and the Ottawa General Hospital, 501 Smyth Road, Ottawa, Canada, KIH 8L6. Thrombocytopenia is a common occurrence among patients with infectious mononucleosis. Severe thrombocytopenia with bleeding is rare. Fatal intracerebral hemorrhage has been reported only once previously in infectious mononucleosis (Goldstein, E. and Porter, D.Y. Arch. Neurol. 20:533-5, 1969). This is a report of the second case of fatal intracerebral hemorrhage complicating thrombocytopenia in infectious mononucleosis. It is being reported because infectious mononucleosis is con~non in young people and usually has few complications. Fatal intracerebral hemorrhage due to thrombocytopenia in infectious mononucleosis needs better recognitio~ A 17 year old male was admitted for fever, malaise, petechiae and cervical lymphadenopathy. The peripheral blood showed a white cell count of 13.6 x I09/L with 30% atypical lymphocytes and a platelet count of 5.0 x 109/L. Heterophil antibodies and antibodies to Epstein Barr virus were present. Two hours after admission, the patient became comatose. A large, right thalamic hematoma was detected and surgically evacuated. At autopsy, the findings in the lymph nodes compatible with infectious mononucleosis. The hemorrhage and ischemic change. Antibodies to not found using an indirect immunofluorescence

and spleen were brain showed platelets were technique.

I05 CASTLEMAN'S DISEASE: LYMPHOIDCELL SUBPOPULATIOP4S J.M.E. Martin and B.A. Ruether; Departments of Pathology and Internal Medicine, Foothills Hospital/University of Calgary, Calgary, Alberta. T2N 2T9 Sections of lymph nodes from 3 patients with Castleman's disease were examined immunohistochemically. Despite multicentric lymph node enlargement in one patient and a variable clinical presentation in all cases, routine paraffin sections were histologically similar and showed changes of the hyaline vascular subtype. Using the ABC ir~unoperoxidase technique, cryostat sections were stained for IgM, IgD, ~and ~light chains and for T cell determinants Leu 1 (Pan T), Leu 3a (helper T) and OKT 8 (suppressor T). Antisera to Leu 7 (natural k i l l e r cells) was also used. For the evaluation of histiocytic cells, trypsinised paraffin sections were stained for lysozyme, u-l-antitrypsin, a-l-antichymotrypsin and S-I00 protein. Within atypical germinal centres there was dense intercellular IgM+ material. The lymphoid mantle was IgM+, IgD+ and polyclonal for light chains. The interfollicular and paracortical zones were populated by T lymphocytes in which subtyping showed only a slight predominance of T-helper cells o v e r T-suppressor cells. T cells/natural k i l l e r cells and histiocytic cells were rarely identified within germinal centres. CLINICAL BIOCHEMISTRY, VOLUME 17, JUNE 1984