Polymerase chain reaction-denaturing gradient gel electrophoresis (PCR/DGGE)-based detection of clonal T-cell receptor gamma gene rearrangements in paraffin-embedded cutaneous biopsies in cutaneous T-cell lymphoproliferative diseases.

Polymerase chain reaction (PCR)-based amplification of T-cell receptor (TCR)-gamma genes is a novel technique that can detect a clone of T cells comprising less than 1% of the total T cells in a lymphoid infiltrate. Besides greater sensitivity than Southern blotting, this technique can be performed with smaller quantities of lower molecular weight genomic DNA as template. We retrospectively analyzed 12 paraffin-embedded biopsies of cutaneous T-cell lymphoma (CTCL), 1 case suspicious for CTCL, 1 case of granulomatous slack skin, and 8 cases of inflammatory skin diseases to determine if PCR-denaturing gradient gel electrophoresis (PCR-DGGE) analysis can detect TCR-gamma gene rearrangements on paraffin-embedded specimens. We were able to amplify Vgamma1-8 TCR sequences in each case and detected a dominant clone in 9 of 12 cases of CTCL and in granulomatous slack skin. We analyzed Vgamma9 sequences in 9 cases of CTCL and detected a dominant clone in 4 cases. This study demonstrates that PCR-DGGE can easily be applied retrospectively to cutaneous biopsies of lymphoproliferative diseases when fresh tissue is not available.     

Detection of clonal T cell receptor gamma gene rearrangements in cutaneous T cell lymphoma by LightCycler-polymerase chain reaction.

Cutaneous T cell lymphoma is thought to be characterized by a monoclonal T cell infiltrate in the skin that can be detected by polymerase chain reaction-based amplification of T cell receptor gamma gene rearrangements. We sought to establish a new, simple, and fast LightCycler-based real-time polymerase chain reaction assay for the detection of monoclonality in cutaneous T cell lymphoma, which was suitable for routine laboratory application. Monoclonal T cell receptor gamma gene rearrangements were detected by polymerase chain reaction with consensus primers using: (i) a thermocycler followed by polyacrylamide gel electrophoresis; (ii) a Light Cycler followed by melting curve analysis; and (iii) a LightCycler and subsequent polyacrylamide gel electrophoresis. The detection limit of monoclonal Jurkat T cells diluted in polyclonal peripheral blood mononuclear cells was: (i) 1--3% by thermocycler--polymerase chain reaction and polyacrylamide gel electrophoresis; (ii) 10% by LightCycler--polymerase chain reaction and melting curve analysis; and (iii) 1% by LightCycler--polymerase chain reaction and polyacrylamide gel electrophoresis. In skin biopsies of 22 cutaneous T cell lymphoma patients, a monoclonal or biclonal T cell infiltrate was detected in: (i) 15 of 22 (68%) by thermocycler--polymerase chain reaction and polyacrylamide gel electrophoresis; (ii) 13 of 22 (59%) by LightCycler--polymerase chain reaction and melting curve analysis; and (iii) 16 of 22 (72%) by LightCycler--polymerase chain reaction and polyacrylamide gel electrophoresis. All three techniques revealed negative results in skin biopsies from 26 patients with benign dermatitis. In conclusion, LightCycler--polymerase chain reaction and melting curve analysis is a fast, simple and specific method to detect monoclonal T cell infiltrates in cutaneous T cell lymphoma. Sensitivity of LightCycler--polymerase chain reaction and polyacrylamide gel electrophoresis is slightly higher compared with sensitivity of thermocycler--polymerase chain reaction and polyacrylamide gel electrophoresis. Melting curve analysis, however, is less sensitive compared with polyacrylamide gel electrophoresis, and in case of negative results of the melting curve analysis, it is recommended to resolve LightCycler--polymerase chain reaction samples by gel electrophoresis.     

Satisfactory remission achieved by PUVA therapy in a case of crisis-type adult T-cell leukaemia/lymphoma with generalized cutaneous leukaemic cell infiltration

We used PUVA therapy in a patient with crisis-type adult T-cell leukaemia/lymphoma and generalized cutaneous leukaemic cell infiltration. PUVA proved very effective in reducing leukaemic cells and in clearing the eruption. To understand the way in which PUVA produced a reduction in the number of leukaemic cells, we examined peripheral blood cells by light and electron microscopy. Light microscopy was of little help, but electron microscopy revealed that PUVA induced apoptosis-like changes in circulating leukaemic cells. This suggests that apoptosis-like changes in leukaemic cells might be the reason for the success of this treatment.     

Clinicopathological features of cutaneous lesions of adult T-cell leukaemia/ lymphoma

BACKGROUND: Adult T-cell leukaemia/lymphoma (ATLL) is a human malignancy associated with human T-cell leukaemia virus type I (HTLV-I). ATLL frequently involves the skin. OBJECTIVES: To correlate the clinicopathological features and prognosis in patients with ATLL and cutaneous lesions. METHODS: We examined the HTLV-I proviral state and the clinicopathological features of the cutaneous lesions in 80 patients with serum anti-ATL antibody, to clarify the correlation between macroscopic/histopathological findings and prognosis. Southern blot analysis was performed in all cases to detect monoclonal HTLV-I proviral DNA integration. RESULTS: The cutaneous lesions of 46 patients were positive for proviral DNA integration. The median survival time of patients with monoclonal proviral DNA integration in cutaneous lesions was 14 months, which was markedly shorter than that of patients negative for proviral DNA integration (72 months). Of the 46 patients with proviral DNA, 21 had solitary or multiple red nodules (including three with subcutaneous induration), eight had multiple red papules and 17 had erythema. Patients with papules and nodules had poorer prognosis than those with erythema. Histopathologically, the prognosis was poorer in patients with nodular or diffuse infiltration of medium-sized to large lymphoma cells, compared with those with perivascular infiltration of small to medium-sized lymphoma cells. CONCLUSIONS: Our results show a close correlation between clinicopathological features of HTLV-I-associated cutaneous lesions and prognosis.     

Southern blot analysis of clonal rearrangements of T-cell receptor gene in plaque lesion of mycosis fungoides

T-cell populations of 22 plaque lesions from seven mycosis fungoides patients were studied for clonal rearrangement of the beta chain of the T-cell receptor (T beta) gene. All plaque lesions employed in this study showed clinically similar appearance. Histologically, all the biopsy specimens showed epidermotropism and the dermal infiltration of mononuclear cells including atypical cells. Histochemically, the majority of the infiltrated cells had surface markers of helper T cells. DNA extracted from skin lesions, peripheral lymphocytes, and lymph nodes revealed that the monoclonal expansion of T cells was different among patients and lesions. DNA extracted from the two skin lesions of case 1 revealed a clonal expansion of T cells. The rearranged bands persisted for about 1 year. In contrast, all lesions from cases 3-7 showed no rearranged band. Interestingly, three lesions from case 2 showed mixed type results, i.e., the monoclonal expansion of T cells was detected in one lesion but not in the other two lesions. Time course study of case 2 revealed that the same rearranged band became detectable in all three skin lesions and a lymph node about 1 year later. These results suggest that in plaque lesions of mycosis fungoides, there are various stages of detectable monoclonality of infiltrating cells, although the clinical appearance of the plaques was similar, and that the variety of monoclonality may reflect the long clinical course of this disease.     

Molecular diagnosis of cutaneous T-cell lymphoma: polymerase chain reaction amplification of T-cell antigen receptor beta-chain gene rearrangements.

The goal of our study was to molecularly diagnose CTCL, by cloning the T-cell antigen receptor beta chain (TCR-beta) gene rearrangement from the malignant T cells of a patient with Sézary syndrome, in order to generate a specific oligonucleotide probe capable of detecting CTCL cells through polymerase chain reaction (PCR) amplification. Total RNA isolated from peripheral blood lymphocytes was reverse transcribed and resultant first strand cDNA was PCR amplified utilizing a concensus primer to the TCR-beta variable region (V beta) and a 3' primer to the TCR-beta constant region (C beta). PCR reaction products were subcloned into a plasmid vector and sequenced. Sequence analysis revealed that the patient's in-frame TCR-beta gene rearrangement utilized V beta 6.4, D beta 1.1, J beta 2.2, and C beta 2.1 gene segments. Oligo-primers to V beta 6.4 and J beta 2.2 were utilized to PCR amplify genomic DNA taken from the patient's blood and involved skin. Screening the amplified DNA with an oligo-probe specific for the patient's V-D-J junctional sequences resulted in the detection of the patient-specific sequences. No sequences were detected from DNA from other malignant or benign infiltrates. Thus, we have defined a "molecular fingerprint" specific for a patient's malignant T-cells and can molecularly diagnose CTCL through PCR amplification.     

New insights into the applicability of T-cell receptor gamma gene rearrangement analysis in cutaneous T-cell lymphoma

BACKGROUND: Detection of clonal T-cell receptor (TCR) gamma gene rearrangement by polymerase chain reaction (PCR) based method is a marker for cutaneous T-cell lymphoma (CTCL) although it can be seen in some benign dermatoses. To determine the accuracy of histologic criteria alone as well as the adjuvant diagnostic role of TCR gene rearrangement for the diagnosis of CTCL, we studied 100 patients with cutaneous T-cell infiltrates by both histology and TCR gene rearrangement. METHODS: The histologic features of the 100 patients were first reviewed by two independent dermatopathologists and their confidence in the diagnosis of CTCL was assigned one of four levels. Then the specimens were analyzed for TCR gene rearrangement either on paraffin-embedded or fresh-frozen tissue by PCR/denaturing gradient gel electrophoresis (DGGE). RESULTS: The clonality was detected in 100% (15/15) diagnostic of, 84.6% (11/13) consistent with, 57.6% (19/33) suggestive of CTCL. In 9 cases TCR gene rearrangement was compared between formalin-fixed and fresh specimens of the same individual, but with different degrees of histologic confidence (no lower than suggestive). In all cases fresh specimens were positive. In 5 of the cases (2-diagnostic, 2-consistent, 1-suggestive) formalin-fixed specimens were positive as well, and in 4 cases (1-consistent, 3-suggestive) formalin-fixed specimens were negative. When TCR gene rearrangement was studied in eight cases on sequential biopsies from the same patient, the clonality was detected in only one or two biopsies in four cases in which the histologic confidence was low (suggestive or nondiagnostic). The TCR gene rearrangement study showed identical banding patterns in lesions from different clinical stages in most patients. However, we observed that in one case, oligoclonal-banding pattern was seen in initial biopsy with histopathologic consistent with CTCL, while monoclonal banding pattern in more advanced lesion. CONCLUSIONS: Our data have demonstrated that TCR gene rearrangement studies by PCR/DGGE are consistently positive regardless of tissue fixation (formalin-fixed, paraffin-embedded vs. fresh-frozen tissue) and biopsy site when the histologic degree of confidence is very high (diagnostic). So, it may be of less importance as an adjuvant to histopathologic diagnosis for the cases with diagnostic CTCL histology. However, TCR gene rearrangement studies are particularly important in earlier cases with less conclusive histology, which provides strong confirmatory evidence of an evolving CTCL. In these cases, multiple biopsies may be required to establish the diagnosis and analysis of fresh tissue is suggested to increases the sensitivity. Moreover, our observation also suggested that some CTCL might not be monoclonal de novo, but oligoclonal instead.     

Comparative analysis of TCR-gamma gene rearrangements by Genescan and polyacrylamide gel-electrophoresis in cutaneous T-cell lymphoma

Demonstrating T-cell clonality has become an important approach supporting a diagnosis of malignant T-cell neoplasms. A comparative study between Genescan analysis, polyacrylamide gel and agarose gel electrophoresis in visualizing T-cell receptor gamma gene rearrangement was performed on 25 biopsy specimens from 18 patients with different forms of cutaneous T-cell lymphomas. Clonality was detected in 17 biopsy specimens when PCR products were evaluated by Genescan analysis. Seventeen showed discrete bands when visualized in polyacrylamide gel and 14 cases were clonal when visualized with agarose gel. In five cases, a clonal population was seen in the gels, but not with Genescan. On sequencing the PCR products we demonstrated non-clonality of these five samples. Our results confirm that PCR-Genescan is a useful, reliable and specific screening method for detecting dominant clones in patients with T-cell lymphoma.     

Nasal-type T/natural killer cell angiocentric lymphoma, Epstein-Barr virus-associated, and showing clonal T-cell receptor gamma gene rearrangement

Nasal-type T/natural killer (NK) cell lymphoma, which often shows an angiocentric growth pattern, is a distinct clinicopathological entity highly associated with the Epstein-Barr virus (EBV). This tumour has a characteristic immunophenotype, whereas the cytological spectrum is broad. It is known that a clonal T-cell receptor (TCR) gene rearrangement is not found in this tumour. However, it is still unresolved as to whether the finding of a clonal TCR gene rearrangement excludes the diagnosis of nasal-type T/NK cell lymphoma. We describe a case of nasal-type T/NK cell angiocentric lymphoma, EBV-associated, and showing clonal TCR gamma gene rearrangement. The patient died of sepsis 5 months after diagnosis in spite of aggressive chemotherapy.     

牛痘样水疱病样皮肤NK/T细胞淋巴瘤一例

患儿男，11岁，面部、手臂出现红斑、水疱4年，四肢肿块、溃疡4个月。逐渐感觉乏力，有不规则间歇发热。体检：体温37.7 ℃。全身淋巴结无明显肿大，口腔，颜面和鼻部皮肤片样轻度浸润的粉红色斑片，四肢见大小不等的暗红色浸润性结节和肿块，结节直径2.0 ~ 18 cm不等，部分表面有坏死和黑色结痂，较大的结节表面形成溃疡，坏死性溃疡深达肌肉并有白色脓性分泌物。皮损边界清楚，质地较硬，有压痛，部分结节周围见到卫星样小结节。取自大腿的皮损病理检查发现，表皮真皮全层至皮下可见大量形态不一、中等大小的肿瘤细胞浸润，肿瘤细胞胞质清晰，核大，扭曲状，染色质丰富，细胞呈巢或散在，可见围管样分布；真皮和皮下见碎核和反应性组织细胞浸润，肿瘤细胞浸入毛囊和外泌汗腺。免疫组化：胞质CD3在核周区可见阳性染色，CD56、CD45RO和TIA-1强阳性（+++），部分肿瘤细胞CD30、CD8和Ki 67阳性（++）。EB病毒编码小核RNA（EBER）阳性，TCR-γ 基因重排阳性。最后诊断为牛痘样水疱病样皮肤NK/T细胞淋巴瘤，这是1例罕见的原发于皮肤长达51个月的进展缓慢的病例。     

Rearranged T-cell receptor gene and positive Epstein-Barr virus-encoded nuclear RNA in an extranodal NK/T-cell lymphoma with cutaneous manifestation only: case study

Natural killer (NK)/cytotoxic T-cell lymphoma, a new type of cutaneous neoplasm, has been described recently in the World Health Organization/European Organization for Research and Treatment of Cancer classification for cutaneous lymphomas. We report an 11-year-old boy who had had erythematous plaques and blisters on his face and hands for 4 years and infiltrating plaques and necrosis on his extremities for 4 months. Routine clinical and laboratory examinations found no primary nasal involvement. Biopsies taken from nasal mucosa and skin showed that the tumour only involved dermis and subcutaneous tissue, and the infiltrated lymphohistiocytic tumour cells were CD56+, TIA+, CD45RO+ and CD30+. In situ hybridization for EBV-encoded nuclear RNA was positive. Clonal T-cell receptor-gamma2 gene rearrangement was positive. A diagnosis of extranodal NK/T-cell lymphoma, nasal type, was made. This is a rare case, with slow course and survival for >51 months with the presentation only occurring in the skin.     

Long-term implications of T-cell receptor gene rearrangement analysis by Southern blot in patients with cutaneous T-cell lymphoma

BACKGROUND: T-cell clonality analysis by Southern blot (TSB) in skin biopsy specimens suggestive of mycosis fungoides may be helpful in confirming the diagnosis of a cutaneous lymphoma. However, there are no data available regarding the long-term prognostic implication of such results. OBJECTIVES: We sought to determine the long-term prognostic significance of TSB results from skin biopsy specimens of patients with mycosis fungoides. METHODS: We reviewed the records from the Cleveland Clinic Foundation and Northwestern University Medical Center for cases of biopsy-proven mycosis fungoides with results available for skin biopsy TSB from 1987 to 1990. RESULTS: The detection of clonality by TSB correlates with a higher TNM stage (median stage for positive TSB, IIb vs negative TSB, Ib; P <.05), but not with age at presentation (62 vs 59 years) or duration of disease before presentation (6.2 vs 5.9 years). Although the long-term survival was not significantly different between the 2 groups, there was a trend for patients with positive TSB to die earlier (5-year survival of 67% vs 87%). Disease progression did not correlate with TSB results. Higher clonality rates were noted among patients with biopsy specimens showing a denser lymphoid infiltrate and a higher grade of cytologic atypia. CONCLUSIONS: Detection of clonality with TSB requires a significant clonal burden. Although clonality can be detected in patients with patches and plaques (T1 and T2) most cases with positive results were obtained from patients with advanced disease (T3 and T4). In our experience, detection of clonality by TSB does not correlate with disease progression and does not carry long-term prognostic implications.     

Detection of clonal T-cell receptor gene rearrangements in the peripheral blood of patients with mycosis fungoides/Sezary syndrome

Involvement of the peripheral blood in mycosis fungoides/Sezary syndrome (MF/SS) has a significant impact upon prognosis, but it is often difficult to distinguish circulating cells of MF/SS from atypical reactive lymphocytes. We compared the standard morphologic method of identifying leukemic cells, the Sezary preparation, to a genotypic method using Southern blot analysis of T-cell receptor gene rearrangements in concurrent blood samples. We studied 26 MF/SS patients, five of them in remission, together with five controls from cases of various non-MF/SS skin diseases. Six of 26 MF/SS patients had morphologically atypical circulating leukocytes (3%, 4%, 5%, 14%, 16%, 19%). Seven of 26 MF/SS patients had clonal T-cell receptor gene rearrangements, including the four patients with the greatest percentages of atypical cells and three patients lacking atypical cells. Six of seven patients had skin disease at the time of sampling, including three with erythroderma, two with generalized thick plaques, and one with generalized patches, while one patient was in clinical remission. All five controls lacked morphologic and genotypic evidence of atypical or clonal T-cells. Relative to genotyping, in our series the Sezary preparation was less sensitive and less specific. There were three apparent false negative results in the Sezary preparations, and two potential false positive (patients with 3% and 4% atypical leukocytes); however, there was agreement between the two techniques in most cases. We conclude that gene rearrangement studies may provide an effective test with which to assess the peripheral blood of MF/SS patients.     

TCRgamma-chain gene rearrangement by PCR-based GeneScan: diagnostic accuracy improvement and clonal heterogeneity analysis in multiple cutaneous T-cell lymphoma samples

Cutaneous T-cell lymphomas are a heterogeneous group of lymphomas where the tumor population emerges within a multiple subclone pattern ("clonal heterogeneity"). PCR analysis has been shown to be useful in the diagnosis of mycosis fungoides (MF) and Sézary Syndrome (SS). Focusing the attention on clonal heterogeneity, the efficacy of the multiplex/heteroduplex (HD) PCR and the GeneScan (GS) capillary electrophoresis analysis was compared in the early diagnosis of MF/SS, using a multiple sample approach. Indeed, GS demonstrated TCRgamma gene rearrangement (GR) in all the 57 SS (100%) and in 123/146 (84%) of the MF samples, whereas the multiplex/HD PCR was less sensitive. An increase in clonality was observed in connection with both a worsening of the cutaneous disease (79% T1/T2; 100% T3/T4) and an increase in the histopathological score (HS < 5, 76%; HS > or = 5, 94%). Clonal heterogeneity with adjunctive reproducible skin TCRgamma-GRs was also observed. "Clonal instability," with different GRs, was present in a small percentage of patients. Therefore, it can be concluded that GS analysis in TCRgamma-GR is able to improve diagnosis in MF/SS patients and the multiple sample approach is helpful for a correct interpretation of clonal patterns in skin lesions, especially in early-stage MF and in SS skin/blood samples.     

原发性皮肤CD4+多形性小/中T细胞淋巴瘤一例

报告1例原发性皮肤CD4+多形性小/中T细胞淋巴瘤.患者男,19岁.全身多发暗红色斑块和小结节2年.皮损组织病理检查示,真皮内血管及附属器周围有致密小到中等大,胞质空亮,核扭曲的淋巴样细胞浸润,可见核分裂像.未见亲表皮性,但有浸润毛囊现象.免疫组化检查显示,CD3阳性、CD4阳性、CD8阴性、CD30阴性和CD20阴性,Ki-67阳性率约为25%.诊断:原发性皮肤CD4+多形性小/中T细胞淋巴瘤.