Immunohistochemical Characterization of a B-Cell Signet Ring Cell Lymphoma

Path. Res. Praet. 183, 497-501 (1988)

Immunohistochemical Characterization of a B-Cell Signet Ring Cell Lymphoma Report of a Case S. Uccini, E. Pescarmona, L. P. Ruco and C. D. Baroni Pathological Anatomy, Dept. of Human Biopathology, University "La Sapienza", Roma, Italy

B. Monarca Haematology, Dept. of Human Biopathology, University "La Sapienza", Roma, Italy

A. Modesti Dept. of Experimental Medicine, University "La Sapienza", Roma, Italy

SUMMARY Signet ring cell lymphoma is a non-Hodgkin's lymphoma, characterized by neoplastic lymphoid signet ring cells very similar to epithelial mucin producing cells. We describe here a case of signet ring eel/lymphoma in which the immunophenotypic markers of signet ring cells parallel those of plasma cells, being intensively T10+ (CD 38), weakly HLA-DR+, and ToH (CD 22) and T200 (CD 45) negative. The morphologic and immunohistochemical features of the case and the main differential diagnosis are preceded by a review of the literature. Introduction The signet ring cell lymphoma is an extremely rare type of non-Hodgkin's lymphoma; it was originally described in 1978 by Kim et aU and was interpreted as a variant of follicular center cell lymphoma. Until now, only 32 cases of signet ring cell lymphoma have been reported. Twentynine of such cases were centrocyticlcentroblastic B cell lymphomas and three were diffuse large T cell lymphomas (Table 1). Signet ring lymphoid cells are characterized by a cytoplasmic mass, similar to that ascribed to mucin-producing cells, displacing the nucleus at the periphery. Immunohistochemistry has demonstrated that the majority of these cases are B cell lymphomas in which the signet Supported by CNR contract N.86.00303.44, Progetto Finalizzato "Oncologia"and by CNR contract N.86.01666.56, Progetto Finalizzato "Medicina Preventiva e Riabilitativa". © 1988 by Gustav Fischer Verlag, Stuttgart

ring cells are immunoglobulin producing plasma cells. Their peculiar appearance is due to an abnormal storage of immunoglobulins. In addition, three cases of signet ring cell lymphoma of T cell origin have been reported, which represent a variant of diffuse large cell lymphoma 3• 16 , mainly composed of mature helper T lymphocytes. We describe the histological, ultrastructural and immunohistochemical features of a case of B signet ring cell lymphoma primary in an axillary lymph node. Case Report

Clinical data A 63-year-old white man with persistent pneumonia was admitted to hospital because of a generalized peripheral adenopathy and splenomegaly. Chest radiographs revealed mediastinal widening. An abdominal CT 0344-0338/88/0183-0497$3.50/0

498 . S. Uccini, E. Pescarmona, L. P. Ruco, C. D. Baroni, B. Monarca and A. Modesti Table 1. Summary of clinical, laboratory and morphologic data (Literature Review) Authors

Case

Age/Sex

Diagnosis

Site of involvement

Igs

Jejunum, mesentery Polyadenopathy Polyadenopathy, spleen Polyadenopathy Polyadenopathy Submandibular "LN Inguinal LN Cervical LN Cervical LN Polyadenopathy, skin rash Mesentery Cervical LN Pelvic LN Cervical LN Retroperitoneal LN Supraclavicular LN Inguinal LN Inguinal LN Polyadenopathy Mesentery, stomach Submandibular LN Supraclavicular LN Retrogastric mass Polyadenopathy Stomach, mesenteric LN Stomach, mesenteric LN Stomach, lung, abdom. LN Thyroid Stomach Polyadenopathy

IgG, L

IgG, K IgM, L IgM, K IgG, KL IgG, K IgM, IgG, IgM, IgA, IgM, IgA, IgM, IgA, IgM, IgA, IgG, L IgA, J IgM, IgA,

Polyadenopathy, skin rash Inguinal LN, skin lesions Subcutaneous nodules

CD2/CD4IDR CD2IDR CD2/CD4IDR

B-Cell type Kim et al. (1978)

Van den Tweel et al. (1978)

Vernon et al. (1979) Iossifides et al. (1980) Moir et al. (1980) Harris et al. (1981) Pileri et al. (1981) Navas-Palacios et al. (1983) Silberman et al. (1983) Hernandez et al. (1985) Allevato et al. (1985) Tungekar (1986) Uccini et al. (current report)

1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 1 1 1 1 1 2 3 1 1 2 3 4 1 1 1

51/F 53/F 51/M 60/F 52/M 76/F 62/F 34/F 62/F 75/M 62/M 56/F 70/M 20/F 42/F 50/F 55/F 57/M 331M 60/F 70/F HIM 76/M 57/F 60/M 54/F 76/M 53/F 46/M 63/M

1 2 1

60/M 57/M 69/M

N&DM N & D PDL N PDL N & D PDL N & D PDL N & D PDL N&DM IS IS IS LC,FCCL LC,FCCL SC,FCCL IS N PDL N PDL N PDL N&D Cc N Cb-Cc D Cb-Cc N & D Cb-Cc N Cb-Cc N&DM N & D PDL N&DM N & D PDL N & D PDL N & D Cb-Cc N & D Cb-Cc

IgG, L IgG, K IgM, K IgM, K IgM, K IgG, K IgM, KL IgG, K IgA, L L IgM, K IgM, K IgG, L IgG, K

K K K K K L

T-Cell type Weiss et al. (1985) Grogan et al. (1985)

D,LCL D,LCL D,LCL

F: female; M: male; N: nodular; D: diffuse; M: mixed type (Rappaport's classification); POL: poorly differentiated lymphocytic; IS: immunoblastic sarcoma (Luke's classification); LC: large cleaved; SC: small cleaved; FCCL: follicular center cell lymphoma; Cb-Cc: centroblastidcentrocytic (Lennert's classification); LCL: large cell lymphoma; K: kappa; L: lambda.

scan was within normal limits. Laboratory values on admission were as follows: hemoglobin 11.3 g/dlj leukocyte count 10000htl, with neutrophilia and normal morphologic features; platelet count 240000; sedimentation rate 42 mrnJhour; serum alkaline phosphatase 799 lUll; serum protein electrophoresis normal. Serum immunoglobulin concentrations: IgG 1039 mg/dl (normal 564-1765 mg/dl); IgA 304 mg/dl (normal 85-385 mg/dl); IgM 246 mg/dl (normal 45-250 mg/dl). Bone marrow aspirate demonstrated an increased cellularity with normal cellular composition. A bone marrow trephine biopsy showed interstitial, multinodular localization of a follicular center cell lymphoma (FCC) characterized by a peculiar signet ring cell component. An enlarged axillary lymph node was then removed for diagnostic purpose.

Histology and immunohistochemistry Light microscopy revealed that the lymph node structure was completely effaced by a nodular centrocytidcentroblastic lymphoma with numerous signet ring cells present in the internodular areas (Fig. 1). These cells are characterized by an abundant eosinophilic and weakly PAS diastase resistant positive cytoplasm, and by a small nucleus displaced at the periphery. Few mitotic figures were observed. Immunohistochemistry on cryostat sections proved that the neoplastic nodules were composed of B cells (CD 19+/CD 20+/CD 22+) admixed with a meshwork of follicular dendritic cells (DRC -1 +/CD 14+) (Fig. 2A). Signet ring cells were numerous in the internodular areas (Fig. 2 B), where reactive T lymphocytes

Signet Ring Cell Lymphoma . 499

Fig. 1. Nodular signet ring cell lymphoma (Haematoxylyn and Eosin, x 250); there are numerous signet ring cells with abundant and eosinophilic cytoplasm and a small nucleus displaced at the periphery (insert, x 1000).

Fig. 3. Immunostaining of paraffin sections with anti-lambda light chains (A x 1000) and of cryostat sections with OKT 10 MoAb (B x 1000). An evident cytoplasmic lamellar positivity is present in signet ring cells.

(CD4+), B lymphocytes (CD 19+/CD20+) and Leu M3+ (CD 14) macrophages were also present. Signet ring cells were immunoreactive for lambda light chain and 19AI IgM heavy chains with a cytoplasmic lamellar pattern (Fig. 3 A). The immunophenotypic characterization demonstrated that they were T 10+ (CD 38) (Fig. 3 B), weakly HLA-DR+ and, like normal plasma cells, they were panleukocyte (CD 45) and pan B (CD 22) negative. The proliferating cells of this lymphoma, as revealed by Ki 67 monoclonal antibody2 were mainly located in the interfollicular areas and were not characterized by signet ring cell morphology.

, ··,t Fig. 2. Immunostaining of cryostat sections with DRC-1 MoAb (A x 100) and of paraffin sections with anti-lambda light chain (B x 100). The B cell nodules, characterized by an irregular meshwork of DRC-1 + follicular dendritic reticulum cells (A) show only few signet ring cells, which are mainly located in the internodular areas (B).

Electron microscopy At ultrastructural level signet ring cells are characterized by dense lamellar crystals which are situated within the dilated cisternae of rough endoplasmic reticulum (Fig. 4). This finding is strictly similar to that described in other B cell malignancies 10.

500 . R. Montironi, M. Scarpelli, M. De Nictolis, G. Mariuzzi, G. Ansuini and E. Pisani

Fig. 4. Detail of the cytoplasm of a signet ring cell (x 27000), showing crystalline inclusions lying within the cisternae of the rough endoplasmic reticulum (insert, x 50000). Discussion Signet ring cells characterize some lymphomas either of B or T cell origin. The signet ring pattern is caused by the production and storage of immunoglobulins in rough endoplasmic reticulum in B lymphoma, and in T lymphoma by the presence of large membrane-bound vacuoles 3,16. Signet ring cells in B lymphoma have been interpreted as plasma cells characterized by Ig synthesis not followed by their release7 • Our immunohistochemical study demonstrated that signet ring cells are T 10+ (CD 38), weakly HLA-DR+ and negative for pan-leukocyte and pan B antibodies, thus indicating that the signet ring cells have phenotypic markers closely similar to those of the normal plasma cells. Our patient presented polyadenopathy and bone marrow involvement. However, the serum concentration of immunoglobulins was within normal limits. This finding indicates the existence in these patients of a non secreting plasma cell tumor. The cellular alteration could therefore depend on an abnormal synthesis of immunoglobulins not followed by their release because of a defective transfer from the rough endoplasmic reticulum to the Golgi complex. The EM demonstration of crystals of immunoglobulins within dilated cisternae of the rough endoplasmic reticulum supports this interpretation. Ki 67 monoclonal antibody reacts with proliferating cells2 and signet ring cells were Ki 67 negative. Therefore our finding suggests that this neoplasia is composed of two

sets of cells: immature proliferating cells Ki 67 + and cells, represented by Ki 67 negative signet ring cells, in which cellular differentiation prevails on proliferation. Our microscopic diagnosis was that of a signet ring cell centrocytidcentroblastic lymphoma primary in a lymph node and immunohistology substantiated this diagnosis. Lymphomatous signet ring cells are very similar to mucin producing cells of gastrointestinal carcinoma. Consequently the most common differential diagnosis concerns signet ring ceillymrhoma and carcinoma primary in gastrointestinal tracf' . Using conventional staining methods the cytoplasm of signet ring cells present in Blymphoma is markedly and diffusely eosinophilic whereas in T celllymphoma the cells appear clear and vacuolated. Finally in carcinoma the mucin producing cell are very numerous and are characterized by a waterly clear cytoplasm. However, only the immunohistochemical demostration of Ig restriction or cytokeratin positivity allows to substantiate the correct diagnosis. Acknowledgements. The authors thank A. Mastracchio and M. Macchiolo for expert technical assistance. References 1

Allevato Pa, Kini SR, Rebuck JW, Miller JM, Hamburger JI

(1985) Signet ring cell lymphoma of the thyroid: a case report. Hum Pathol16: 1066-1068

Letter to the Case . 501 2 Gerdes 1, Schwab U, Lemke H, Stein H (1983) Production of a mouse monoclonal antibody reactive with a human nuclear antigen associated with cell proliferation. IntI Cancer 31: 13-20 3 Grogan TM, Richter LC, Payne CM, Rangel CS (1985) Signet-ring cell lymphoma of T-cell origin. An immunocytochemical and ultrastructural study relating giant vacuole formation to cytoplasmic sequestration of surface membrane. Am 1 Surg Pathol 9: 684-692 4 Harris M, Eyden B, Read G (1981) Signet ring cell lymphoma: A rare variant of follicular lymphoma. 1 Clin Pathol 34:

884-891

5 Hernandez la, Sheehan WW (1985) Lymphomas of the mucosa-associated lymphoid tissue. Signet ring cell lymphomas presenting in mucosal lymphoid organs. Cancer 55: 592-597 6 Iossifides I, Mackay B, Butler 11 (1980) Signet ring celllymphoma. U1trastruct Pathol 1: 511-517 7 Kim H, Dorfman RF, Rappaport H (1978) Signet ring cell lymphoma: a rare morphologic and functional expression of nodular (follicular) lymphoma. Am 1Surg Pathol 2: 119-132 8 Moir DH (1980) Signet ring cell lymphoma: a case report. Pathology 12: 119-122 9 Navas-Palacios 11, Valdes MD, Lahuerta-Palacios 11 (1983) Signet ring cell lymphoma. Ultrastructural and immunohistochemical features of three varieties. Cancer 52: 1613-1623

10 Pileri S, Serra L, Govoni E, Martinelli G (1981) Signet ring cell lymphoma: A case report. Histopathology 5: 165-173 11 Sanel FT, Lepore Ml (1968) Granular and crystalline deposits in perinuclear and ergastoplasmic cisternae of human lamina propria cells. Exp Molec Pathol 9: 110 12 Silberman S, Fresco R, Steinecker PH (1984) Signet ring cell lymphoma. Areport of a case and review of the literature. Am 1 Clin Pathol 81: 358-363 13 Turgekar MF (1986) Gastric signet-ring cell lymphoma with alpha heavy chains. Histopathology 10: 725-733 14 Van den Tweel IG, Taylor CR, Parker lW, Lukes Rl (1978) Immunoglobulin inclusions in non-Hodgkin's lymphomas. Am 1 Clin Pathol 69: 306-313 15 Vernon S, Voet RL, Naiem F, Waisman 1 (1979) Nodular lymphoma with intracellular immunoglobulin. Cancer 44:

1273-1279

16 Weiss LM, Wood GS, Dorfman RF (1985) T-cell signet-ring cell lymphoma. A histologic, ultrastructural, and immunohistochemical study of two cases. Am 1Surg Pathol 9: 273-280

Received November 9, 1987 . Accepted lanuary 26, 1988

Key words: Signet ring eel/lymphoma - Plasma cells - Lymphoma, Metastatic carcinoma - Immunohistochemistry Stefania Uccini, MD, II Cattedra di Anatomia Patologica, Universita "La Sapienza", Viale Regina Elena 324, 00161 Roma, Italy

Letter to the Case J. Diebold Paris

Uccini et al. report a new case of so called "signet ring B cell lymphoma". Their interesting review of the literature demonstrated that most of the cases were discovered in patients over 40, with a slight predominance for women (F/M = 17/12 = 1,4). As far as we know 3 other published cases can be added (see Table 1) bringing the total number of B cell type cases to 32 1,3. Most of the cases exhibited a diffuse and a nodular pattern, and were predominantly composed of small cells. The follow-up of most of the cases corresponded to a low grade malignant lymphoma. Only one case was a large cell ML 1• Uccini et al. underline the peculiar topography of the signet ring cells, which accumulate around the nodules. So this type of B cell ML can be regarded as a follicular ML associated with the accumulation of B immunosecreting

cells with a peculiar pattern of signet ring cells. We described the same pattern in four cases of malignant lymphomas of a follicular centroblastic centrocytic type associated with a monotypic lym~hoplasmacytic cell infiltrate around the tumour follicles . Ultrastructural studies allow to recognize 3 types of intracytoplasmic inclusions responsible for the signet ring aspect. One appears as a large vacuole limited by a single membrane. The lumen is empty or contains only a few microvesicules situated at the periphery. More rarely, these microvesicules filled the vacuoles. At the histological levels, these empty vacuoles are clear and PAS negative. They did not contain large immunoglobulin deposits. Immunoglobulins, when present, were disclosed at the periphery of the vacuoles near the membrane. In most of the cases, these immunoglobulins were monoclonal IgG