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Bone marrow mast cell content in preleukemic syndrome
Bone Marrow Mast Cell Content in Preleukemic Syndrome
DAL YOO, M.D. LAWRENCE S. LESSIN, M.D. Washington,D.C.
Bone marrow mast cell content was evaluated by a semiquantltative method in 22 marrow specimens from 20 patients with preleukemic syndrome and was compared with 21 marrow specimens from iron-deficient control subjects. Results indicate a statistically sig nificant increase of bone marrow mast cell content in patients with preleukemic syndrome in comparison to control subjects (p SO.0005). Two of 20 preleukemic patients converted to acute myeloblastic leukemia and conversion was accompanied by a significant decrease of bone marrow mast cell content. Our findm indicate that bone marrow mast cell content can be reproducibly quantitated and represents an additional morphologic criterion for diagnosis of the preleukemic syndrome. Increased bone marrow mast cell content has been observed in lymphoproliferative disorders [ 1,2] and more recently in acute leukemia and preleukemic syndromes [3]. Despite the fact that morphologic criteria have been proposed for diagnosis of the preleukemic syndrome [4,5], the addition of increased bone marrow mast cell content to these criteria should increase diagnostic accuracy. We, therefore, quantitated mast cell content in bone marrow specimens from 20 patients with preleukemic syndrome and found a significant increase in mast cell content (p iO.0005) over iron-deficient control marrows. MATERIAL AND METHODS
Fromthe departmentsof MedicinearxlPathology, ProvidenceHospital,and the Divisionof Hemaosparbnentof f&dklne, George tology-oncology. Washington University Medical Center, Washington,D.C. Requestsfor reprintsshouldbe addressedto Dr. Dal Yoo, Departmentsof Medicine and Pathology,ProvidertoeHospital.Washington, D.C. 20017. Manuscriptaccepted February24, 1982.
Twenty-two bone marrow specimens from 20 patients with preleukemic syndrome were analyzed for mast cell content and compared with bone marrow specimens from 21 patients with iron-deficiency anemia due to benign causes. Patients with an underlying neoplastic, inflammatory, or infectious basis for gastrointestinal or uterine blood loss were excluded. Two of the 20 preleukemic patients converted to acute myeloblastic leukemia: bone marrow mast cell content was compared before and after leukemic conversion. Preleukemic syndrome was defined according to the criteria of Linman and Bagby [4] and included patients with a refractory anemia (18 patients), neutropenia (1 patient), and pancytopenia (1 patient) with normocellular to hypercellular marrows showing megaloblastoid dyserythropoiesis. Abnormal granulopoiesis and mononuclear megakaryocytes were present in most patients, but diagnosis of acute leukemia could not be made. There were less than 10 percent myeloblasts in all marrow specimens studied. Absence of vitamin B12 or folate deficiency and refractoriness to their administration was demonstrated in all patients. None had ever received cytotoxic therapy. The 20 patients with preleukemic syndrome included 12 men and 8 women, ranging in age from 23 to 84 years, with a mean age of 59.2 years. The 21
October 1982
The American Journal ot Medlclne
Volume 73
539
BONE MARROW MAST CELL CONTENT-Y00
AND LESSIN
Figure 1. Photomicrograph of bone marrow specimen showing the placement of eyepiece micrometer for mast cell estimation. Rounded oval, or elongated, darkly stained mast cells are easily discerned from the background of marrow particles. The length of the micrometer bar is 200 p and the bar in the right lower portion corresponds to 75 p. (Wright-Giemsa stain; original magnification X 400, reduced by 33 percent.)
control subjects with iron deficiency consisted of 7 men and 14 women, ranging in age from 18 to 87 years, with a mean of 52.8 years. Bone marrow smears, prepared without anticoagulant, were fixed and stained by the standard Wright-Giemsa method. Bone marrow mast cells were morphologically identified as rounded, oval, or elongated, of varying size with cytoplasm, packed with characteristic dense, dark bluepurple granules and occasionally with a clear area at the site of the nucleus (Figure 1). Bone marrow mast cell quantitation was performed by the method previously reported [2]. In each marrow specimen, a minimum of 5 to 10 randomly selected 0.2 by 0.2 mm (0.04 mm*) fields were counted within peripheral translucent margins of five or more separate marrow particles (Figure 1). Bone marrow specimens, lacking five or more separate particles, were excluded from the study. The number of mast cells was calculated for each specimen per 0.04 mm* and then uniformly expressed as mast cell number per 1 mm*. Each slide was counted at least twice by a single examiner using blinded slides. RESULTS
As shown in Figure 2, the number of wow mast cells per square millimeter (mm*) expressed as mean f standard deviation was 25.0 f 13.2 in iron-deficient control marrows, as compared with 214.8 f 102.9 in preleukemic marrow samples. Statistical differences of mean mast cell counts and standard deviations between the iron-deficient control group and preleukemic
540
October
1982
The American
Journal d Medicine
group were highly significant with p 10.0005
by Stu-
dent’s t test. These results indicate that marrow mast cell content was significantly elevated above control levels in pa-
tients with preleukemic syndrome. In two patients, progression from the preleukemic state to acute myeloblastic leukemia was accompanied by a fall in marrow mast cell content from 2 12.5 to 35.0 per mm* and 352.5 to 92.5 per mm*, respectively. COMMENTS Quantitative variations of bone marrow mast cells have
in a variety of hematologic and nonhematologic disorders [2,3]. Marrow mast cells are characterized by their abundant dark blue-purple staining granulation and are usually found to be tissue-fixed within marrow particles, most often located along vascular structures. The present study has demonstrated that the bone marrow mast cell content is significantly increased in patients with preleukemic syndrome as defined by Linman and Bagby [4]. The mechanism or pathophysiologic significance of increased bone marrow mast cell content in patients with preleukemic syndrome remains unclear. Because of the role of the mast cell with its immunoglobulin E receptors in cellular immune reactions, it is conceivable that the increased bone marrow mast cells represents an expression of the host imbeen described
Volume 73
BONE MARROW MAST CELL CONTENT-Y00
AND LESSIN
. (507.5) :
.* N=22
” Z=214.8 * SD=102.9
F&we 2. Graphic hmonstration of mf4stcells per squaremi/hat49r fur each ~rocy,studid showhg mean valuewith standarddeviation.Iron&ficient control @oup consists of 2 1 rlxwow specimens from 21 patients and tfh9 prekdhkemic group, 22 msrrow sp&mens from 20 patients.
IRON.DEFICIENCY CONTROLS
munofogic reaction against the malignant preleukemic cell clone. This concept is supported by both hwnan and animal studies. In a study of patients wfth breast cancer, the axikty lymph node mast cell content correlated with postoperative survival, suggesting that the number of iymph node mast ceils reflected host cytotoxic immune response [6]. In the mouse skin model carcinogenesis system, the promotion phase was accompanied by a mast cell reaction in the upper dermis, suggestive of an immune response [7]. More recentfy, mouse mast cells from peritoneal washings were found to have cytotoxic antitumor effects against mouse methylchotanthreneinduced fibrosarcorna cells, when tested in an in vitro microcytotoxicity assay system [ 81. the observation that growth of certain solid neo-
PRELEUKEMIC PATIENTS
plasms is dependent upon the tumor’s capacity to elicit the development of new capillary endothelium (tumor angiogenesis factor) suggests another possible mechanism. This factor, a diffusible material released by the tumor, induces vascular proliferation in the host which enables a tumor to grow beyond the size attainable by a simple diffusion of nutrients. When tumor angiogenesis factor was implanted to the chorioallantoic membrane of the chick embryo, a 40-fold increase in mast cell density was observed within the vicinity of this implant within 24 hous, suggesting an association between mast cells and tumor angiogenesis [9]. Whether the mast cell response seen in human preleukemia represents a concomitant mechanism of neoplastlc anglogenesis remains to be determined.
Oclobu 1992
The AmukanmolB
volum73
541
BONE MARROW MAST CELL CONTENT-Y00
AND LESSIN
The decrease in bone marrow mast cell content accompanying transition to acute leukemia was observed in two cases. Although the pathogenetic mechanism for this change is unknown, fall in bone marrow mast cell content may be a predictive factor for leukemic conversion. In conclusion, the data obtained in this study indicate that bone marrow specimens from patients with preleukemia have increased mast cell content and that
mast cell determination is useful as an additional morphologic criterion in the diagnosis of preleukemic syndrome. Progressive decrease in mast cell content in these patients may herald transition to acute myeloblastic leukemia. ACKNOWLEDGMENT
We wish to thank Dr. Geraldine P. Schechter for permitting us to use her case materials.
REFERENCES 1. 2.
3.
4.
542
Nixon RK: The relation of mastocytosis and lymphomatous disease. Ann Intern Med 1966; 64: 856-860. Yoo D, Lessin LS, Jensen WN: Bone marrow mast cells in lymphoproliferative disorders. Ann Intern Med 1978; 88: 753-757. Prokocimer M, Polliack A: Increased bone marrow mast cells in preleukemic syndromes, acute leukemia, and lymphoproliferative disorders. Am J Clin Pathol 1981; 75: 34-38. Linman JW, Bagby CC: The preleukemic syndrome (hemopoietic dysplasis). Cancer 1978; 42: 854-864.
October
1982
The American
Journal of Medicine
5. 6.
7.
8. 9.
Volume 73
Dreyfus B: Preleukemic states. Blood Cells 1976; 2: 33-55. Bowers HM, Mahapatro RC, Kennedy JW: Numbers of mast cells in the axillary lymph nodes of breast cancer patients. Cancer 1979; 43: 568-573. Riley JF: Mast cell reaction in precancerous mouse skin: an immunological response? Experientia 1976; 32: 14661467. Farram E, Nelson DS: Mouse mast cells as anti-tumor effector cells. Cell lmmunol 1980; 55: 294-301. Kessler DA, Langer RS, Pless NA, Folkman J: Mast cells and tumor angiogenesis. Int J Cancer 1976; 18: 703-709.
DAL YOO, M.D. LAWRENCE S. LESSIN, M.D. Washington,D.C.
Bone marrow mast cell content was evaluated by a semiquantltative method in 22 marrow specimens from 20 patients with preleukemic syndrome and was compared with 21 marrow specimens from iron-deficient control subjects. Results indicate a statistically sig nificant increase of bone marrow mast cell content in patients with preleukemic syndrome in comparison to control subjects (p SO.0005). Two of 20 preleukemic patients converted to acute myeloblastic leukemia and conversion was accompanied by a significant decrease of bone marrow mast cell content. Our findm indicate that bone marrow mast cell content can be reproducibly quantitated and represents an additional morphologic criterion for diagnosis of the preleukemic syndrome. Increased bone marrow mast cell content has been observed in lymphoproliferative disorders [ 1,2] and more recently in acute leukemia and preleukemic syndromes [3]. Despite the fact that morphologic criteria have been proposed for diagnosis of the preleukemic syndrome [4,5], the addition of increased bone marrow mast cell content to these criteria should increase diagnostic accuracy. We, therefore, quantitated mast cell content in bone marrow specimens from 20 patients with preleukemic syndrome and found a significant increase in mast cell content (p iO.0005) over iron-deficient control marrows. MATERIAL AND METHODS
Fromthe departmentsof MedicinearxlPathology, ProvidenceHospital,and the Divisionof Hemaosparbnentof f&dklne, George tology-oncology. Washington University Medical Center, Washington,D.C. Requestsfor reprintsshouldbe addressedto Dr. Dal Yoo, Departmentsof Medicine and Pathology,ProvidertoeHospital.Washington, D.C. 20017. Manuscriptaccepted February24, 1982.
Twenty-two bone marrow specimens from 20 patients with preleukemic syndrome were analyzed for mast cell content and compared with bone marrow specimens from 21 patients with iron-deficiency anemia due to benign causes. Patients with an underlying neoplastic, inflammatory, or infectious basis for gastrointestinal or uterine blood loss were excluded. Two of the 20 preleukemic patients converted to acute myeloblastic leukemia: bone marrow mast cell content was compared before and after leukemic conversion. Preleukemic syndrome was defined according to the criteria of Linman and Bagby [4] and included patients with a refractory anemia (18 patients), neutropenia (1 patient), and pancytopenia (1 patient) with normocellular to hypercellular marrows showing megaloblastoid dyserythropoiesis. Abnormal granulopoiesis and mononuclear megakaryocytes were present in most patients, but diagnosis of acute leukemia could not be made. There were less than 10 percent myeloblasts in all marrow specimens studied. Absence of vitamin B12 or folate deficiency and refractoriness to their administration was demonstrated in all patients. None had ever received cytotoxic therapy. The 20 patients with preleukemic syndrome included 12 men and 8 women, ranging in age from 23 to 84 years, with a mean age of 59.2 years. The 21
October 1982
The American Journal ot Medlclne
Volume 73
539
BONE MARROW MAST CELL CONTENT-Y00
AND LESSIN
Figure 1. Photomicrograph of bone marrow specimen showing the placement of eyepiece micrometer for mast cell estimation. Rounded oval, or elongated, darkly stained mast cells are easily discerned from the background of marrow particles. The length of the micrometer bar is 200 p and the bar in the right lower portion corresponds to 75 p. (Wright-Giemsa stain; original magnification X 400, reduced by 33 percent.)
control subjects with iron deficiency consisted of 7 men and 14 women, ranging in age from 18 to 87 years, with a mean of 52.8 years. Bone marrow smears, prepared without anticoagulant, were fixed and stained by the standard Wright-Giemsa method. Bone marrow mast cells were morphologically identified as rounded, oval, or elongated, of varying size with cytoplasm, packed with characteristic dense, dark bluepurple granules and occasionally with a clear area at the site of the nucleus (Figure 1). Bone marrow mast cell quantitation was performed by the method previously reported [2]. In each marrow specimen, a minimum of 5 to 10 randomly selected 0.2 by 0.2 mm (0.04 mm*) fields were counted within peripheral translucent margins of five or more separate marrow particles (Figure 1). Bone marrow specimens, lacking five or more separate particles, were excluded from the study. The number of mast cells was calculated for each specimen per 0.04 mm* and then uniformly expressed as mast cell number per 1 mm*. Each slide was counted at least twice by a single examiner using blinded slides. RESULTS
As shown in Figure 2, the number of wow mast cells per square millimeter (mm*) expressed as mean f standard deviation was 25.0 f 13.2 in iron-deficient control marrows, as compared with 214.8 f 102.9 in preleukemic marrow samples. Statistical differences of mean mast cell counts and standard deviations between the iron-deficient control group and preleukemic
540
October
1982
The American
Journal d Medicine
group were highly significant with p 10.0005
by Stu-
dent’s t test. These results indicate that marrow mast cell content was significantly elevated above control levels in pa-
tients with preleukemic syndrome. In two patients, progression from the preleukemic state to acute myeloblastic leukemia was accompanied by a fall in marrow mast cell content from 2 12.5 to 35.0 per mm* and 352.5 to 92.5 per mm*, respectively. COMMENTS Quantitative variations of bone marrow mast cells have
in a variety of hematologic and nonhematologic disorders [2,3]. Marrow mast cells are characterized by their abundant dark blue-purple staining granulation and are usually found to be tissue-fixed within marrow particles, most often located along vascular structures. The present study has demonstrated that the bone marrow mast cell content is significantly increased in patients with preleukemic syndrome as defined by Linman and Bagby [4]. The mechanism or pathophysiologic significance of increased bone marrow mast cell content in patients with preleukemic syndrome remains unclear. Because of the role of the mast cell with its immunoglobulin E receptors in cellular immune reactions, it is conceivable that the increased bone marrow mast cells represents an expression of the host imbeen described
Volume 73
BONE MARROW MAST CELL CONTENT-Y00
AND LESSIN
. (507.5) :
.* N=22
” Z=214.8 * SD=102.9
F&we 2. Graphic hmonstration of mf4stcells per squaremi/hat49r fur each ~rocy,studid showhg mean valuewith standarddeviation.Iron&ficient control @oup consists of 2 1 rlxwow specimens from 21 patients and tfh9 prekdhkemic group, 22 msrrow sp&mens from 20 patients.
IRON.DEFICIENCY CONTROLS
munofogic reaction against the malignant preleukemic cell clone. This concept is supported by both hwnan and animal studies. In a study of patients wfth breast cancer, the axikty lymph node mast cell content correlated with postoperative survival, suggesting that the number of iymph node mast ceils reflected host cytotoxic immune response [6]. In the mouse skin model carcinogenesis system, the promotion phase was accompanied by a mast cell reaction in the upper dermis, suggestive of an immune response [7]. More recentfy, mouse mast cells from peritoneal washings were found to have cytotoxic antitumor effects against mouse methylchotanthreneinduced fibrosarcorna cells, when tested in an in vitro microcytotoxicity assay system [ 81. the observation that growth of certain solid neo-
PRELEUKEMIC PATIENTS
plasms is dependent upon the tumor’s capacity to elicit the development of new capillary endothelium (tumor angiogenesis factor) suggests another possible mechanism. This factor, a diffusible material released by the tumor, induces vascular proliferation in the host which enables a tumor to grow beyond the size attainable by a simple diffusion of nutrients. When tumor angiogenesis factor was implanted to the chorioallantoic membrane of the chick embryo, a 40-fold increase in mast cell density was observed within the vicinity of this implant within 24 hous, suggesting an association between mast cells and tumor angiogenesis [9]. Whether the mast cell response seen in human preleukemia represents a concomitant mechanism of neoplastlc anglogenesis remains to be determined.
Oclobu 1992
The AmukanmolB
volum73
541
BONE MARROW MAST CELL CONTENT-Y00
AND LESSIN
The decrease in bone marrow mast cell content accompanying transition to acute leukemia was observed in two cases. Although the pathogenetic mechanism for this change is unknown, fall in bone marrow mast cell content may be a predictive factor for leukemic conversion. In conclusion, the data obtained in this study indicate that bone marrow specimens from patients with preleukemia have increased mast cell content and that
mast cell determination is useful as an additional morphologic criterion in the diagnosis of preleukemic syndrome. Progressive decrease in mast cell content in these patients may herald transition to acute myeloblastic leukemia. ACKNOWLEDGMENT
We wish to thank Dr. Geraldine P. Schechter for permitting us to use her case materials.
REFERENCES 1. 2.
3.
4.
542
Nixon RK: The relation of mastocytosis and lymphomatous disease. Ann Intern Med 1966; 64: 856-860. Yoo D, Lessin LS, Jensen WN: Bone marrow mast cells in lymphoproliferative disorders. Ann Intern Med 1978; 88: 753-757. Prokocimer M, Polliack A: Increased bone marrow mast cells in preleukemic syndromes, acute leukemia, and lymphoproliferative disorders. Am J Clin Pathol 1981; 75: 34-38. Linman JW, Bagby CC: The preleukemic syndrome (hemopoietic dysplasis). Cancer 1978; 42: 854-864.
October
1982
The American
Journal of Medicine
5. 6.
7.
8. 9.
Volume 73
Dreyfus B: Preleukemic states. Blood Cells 1976; 2: 33-55. Bowers HM, Mahapatro RC, Kennedy JW: Numbers of mast cells in the axillary lymph nodes of breast cancer patients. Cancer 1979; 43: 568-573. Riley JF: Mast cell reaction in precancerous mouse skin: an immunological response? Experientia 1976; 32: 14661467. Farram E, Nelson DS: Mouse mast cells as anti-tumor effector cells. Cell lmmunol 1980; 55: 294-301. Kessler DA, Langer RS, Pless NA, Folkman J: Mast cells and tumor angiogenesis. Int J Cancer 1976; 18: 703-709.