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Adult T-cell leukemia-lymphoma (ATLL) is caused by human T-cell lymphotropic virus type 1 (HTLV-1) and little is known about ATLL endemic to the Caribbean basin and Latin America, designated as western ATLL (W-ATLL). Due to extensive systemic involvement and nonspecific clinical presentation, the initial diagnosis in this cohort can be very challenging. We have diagnosed 60 patients with W-ATLL over a 14-year period. ATLL involves the peripheral blood, bone marrow, and cerebrospinal fluid (CSF) in 98, 87, and 52% cases, respectively; while lymphadenopathy, pulmonary infiltrates, splenomegaly, and hepatomegaly was present in 90, 82, 48, and 45% patients, respectively. While 87% patients developed hypercalcemia only 28% had lytic bone lesions. We propose that any diagnosis of a peripheral T-lymphoproliferative disorder should result in a comprehensive review of the patient's endemic, laboratory information, HTLV-1 testing for proper diagnosis, and identification due to the varied manifestations of this disease.

Introduction: Adult T-cell leukemia-lymphoma (ATL) is an aggressive variant of peripheral T-cell lymphoma of CD4+ T-malignant cells caused by human T-lymphotropic virus type-1. Despite aggressive treatment with multidrug combination chemotherapies, ATL confers a poor prognosis and commonly develops resistance to conventional treatments. Areas covered: Mogamulizumab is a humanized, defucosylated monoclonal antibody that acts by targeting the CC chemokine receptor 4 (CCR4) on malignant cells of ATL. In phase I and II clinical trials, it has achieved overall response rates of 31-50% in CCR4+ malignancies. The most commonly observed hematologic and non-hematologic adverse events included lymphocytopenia, neutropenia, leukocytopenia, infusion reaction, rash, and pyrexia. Expert commentary: Mogamulizumab has shown significant efficacy in treating ATL with moderately high response rates and has been approved in Japan for use in ATL. It may serve as a bridge therapy to achieve disease control prior to allogeneic hematopoietic stem cell transplantation. It also offers potential for use in combination with conventional chemotherapy. Determining the optimal combination of mogamulizumab with conventional and novel therapies remains an important strategy to improve the prognosis of patients with ATL.

Interleukin-7 (IL-7) mediates T-cell homeostasis through its effects on T-cell development, survival and function. In human T-cell lymphotropic virus type 1 (HTLV-1) infection, which is causally implicated in adult T-cell leukemia (ATL), the efficiency with which CD8(+) cytotoxic T-lymphocytes (CTLs) clear HTLV-1-infected cells mediates viral control and may be related to disease progression. We report here that CD127 expression in CD8(+) T-cells is independently related to disease status, and that exogenous IL-7 enhances CD8(+) T-cell survival and clearance of HTLV-1 infected cells in vitro. We conclude that CD127 down-regulation may be associated with disease status in HTLV-1 infection, and propose that exogenous IL-7 may be useful immunotherapy or cytokine adjuvant for an anti-ATL therapeutic vaccine.

Extranodal adult T-cell leukemia/lymphoma (ATLL) of the head and neck is a rare disease. We studied the clinicopathological features of nine patients with ATLL involving extranodal head and neck sites and conducted a literature review. Six patients presented with extranodal mass of the head and neck, whereas three had disseminated diseases. Tumors involved the parotid gland, sinonasal tract, masseter muscle, mandible and skull. Histopathology included diffuse pleomorphic-type (with angiocentric features), Hodgkin-like and anaplastic large cell-type. Five patients with localised disease showed prolonged survival regardless of unfavourable histology and/or aberrant provirus status, including integration of multiple copies or defective provirus. Patients with localised disease documented in the literature, including our study series, had a reduced frequency of elevated lactate dehydrogenase, no hypercalcemia and longer survival. ATLL should be included in the differential diagnosis of extranodal head and neck lymphoma. Localised extranodal ATLL of the head and neck may exhibit indolent clinical behaviours.

The NK-like family of homeobox genes includes TLX1, TLX3 and NKX2-5, which are ectopically activated in distinct subsets of T-cell acute lymphoblastic leukemia (T-ALL) cells. Here we analysed their effect on the miR-17-92 cluster overexpressed in several types of cancer, including T-ALL. The pri-miR-17-92 polycistron encodes micro-RNAs (miRNAs), which decrease E2F1 protein expression, regulating proliferation and/or apoptosis. Quantification of pri-miR-17-92 in T-ALL cell lines suggested an implication of the NK-like homeodomain proteins in transcriptional regulation. Lentiviral-mediated overexpression of NKX2-5 in the T-ALL cell line MOLT-4 consistently resulted in increased miR-17-92 pri-miRNA levels and decreased amounts of E2F1 protein. Induction of apoptosis by treating miR17-92 or E2F1 transduced T-ALL cells with etoposide led to reduced or enhanced cell viability, respectively. Furthermore, analysis of pri-miR-17-92 in T-ALL patients indicated elevated expression in those bearing TLX1/3 positive cells. These data support an activatory effect of NK-like homeodomain proteins on pri-miR-17-92 expression and concomitantly reduced E2F1 protein levels, thereby enhancing survival of leukemic T-cells.

To distinguish the similarities or differences between T-cell acute lymphoblastic leukaemia (T-ALL) and T-cell lymphoblastic lymphoma (T-LBL), we retrospectively analyzed the clinical, immunophenotypic, cytogenetic, and molecular characteristics in 37 children diagnosed between December 1990 and December 2003. Comparative Expressed Sequence Hybridisation (CESH) was used to determine gene expressing profile in both diseases. Twenty two patients suffered from T-ALL and 15 patients were diagnosed as T-LBL. Immunophenotyping demonstrated a more immature phenotype in T-ALL and a more mature phenotype in T-LBL. Cytogenetic and molecular genetic aberrations were found in 82% of T-ALL compared with 73% of T-LBL. By CESH gene expression profiling, the investigated cases were segregated into two groups that largely corresponded with T-ALL and T-LBL. The clinical presentation and cytogenetic characteristics are largely similar for T-ALL and T-LBL supporting the concept that both represent a spectrum of one single disease. The differences that were found between both neoplasms, in particular in their phenotype and in their expression profile may suggest that most T-ALL derive from a T-cell progenitor of the bone marrow, while thymocytes represent the normal counterpart of T-LBL.

Adult T-cell leukemia (ATL) is a malignancy of mature T cells that is etiologically associated with human T-cell leukemia virus type 1 (HTLV-1). The frequent manifestation of ATL is infiltration of leukemic cells into various organs. Besides certain cell adhesion molecules and matrix metalloproteineses, chemokine receptors may play important roles in tissue infiltration of ATL. Identification of a unique set of chemokine receptors expressed by ATL would thus provide valuable information about the molecular mechanism of tissue infiltration of ATL. This may also reveal that ATL frequently develops from a certain subset of T cells that express a particular set of chemokine receptors. Since HTLV-1 encodes a potent viral transcriptional activator Tax, which is known to induce various cellular genes, expression of some chemokine receptors may be affected by Tax. This, however, may relate more to HTLV-1-infected T cells, since ATL cells usually do not express Tax. Finally, identification of a unique set of chemokine receptors expressed by ATL may also provide a new therapeutic target. These considerations prompted us to examine the chemokine receptor expression in ATL. We found that in the majority of ATL cases, leukemic cells consistently express CCR4. Since CCR4 is known to be involved in T cell migration into skin, this may in part explain the frequent skin infiltration in ATL. Furthermore, CCR4 is known to be selectively expressed by Th2 and regulatory T cells. Thus, the majority of ATL may predominantly originate from either Th2 or regulatory T cells.

A small population of human T-cell leukemia virus Type I (HTLV-I) carriers develop adult T-cell leukemia after a long incubation period. The results of a series of experiments using animal models suggest that insufficiency of HTLV-I-specific T-cell response induced by vertical HTLV-I infection allows enlargement of the HTLV-I-infected cell reservoir in vivo, a crucial risk factor of adult T-cell leukemia. In this review it is proposed that prophylactic Tax-targeted vaccines for the high-risk group of adult T-cell leukemia, which is characterized by low HTLV-I-specific T-cell response and high proviral load, can reduce the risk. Immunological studies on adult T-cell leukemia patients after hematopoietic stem cell transplantation also suggest that Tax-targeted immunotherapy may be effective against full-blown disease, although its indication may be limited.

Apoptosis is the primary mechanism through which most chemotherapeutic agents induce tumor cell death. The balance in the expression of pro (Fas/CD95) and anti-apoptotic protein (Bcl-2) may control the response of leukemic cells to chemotherapy and subsequently affect the patient's prognosis. The aim of this study was to determine the levels of Bcl-2 and Fas expression on blast cells from patients with acute leukemia and to correlate the degree of expression to the clinical and laboratory prognostic factors and the patient's outcome. Forty newly diagnosed patients with acute leukemia (16 ALL, 24 AML) were included in the study. Ten normal subjects of matched age and sex were studied as a reference control group. The degree of Bcl-2 and Fas expression on acute leukemia blast cells were assessed before the start of therapy and on mononuclear cells after 1 year of follow up, using flow cytometry. The degree of Bcl-2 and Fas expression were significantly higher in AML (P<0.01,<0.05, respectively) and ALL (P<0.01, <0.05, respectively) as compared to controls. The expression of Fas and Bcl-2 was related to FAB type with the highest Bcl-2 and lowest Fas expression in M5 and T-ALL (P<0.01, for all). In ALL, patients responding to induction chemotherapy revealed lower Bcl-2 and higher Fas expression when compared to non-responders (P<0.05). In contrast, in AML the difference between responders and non-responders to induction chemotherapy regarding Bcl-2 and Fas expressions was not statistically significant (P>0.05). Bcl-2 and Fas expression were significantly elevated in the relapsed acute leukemia group (in both AML and ALL) when compared to those in remission (P<0.01, <0.05, respectively). Bcl-2 and Fas expression at diagnosis was not significantly different when those surviving were compared to the group who had died, either in the ALL or AML groups (P>0.05). Bcl-2 expression was significantly correlated to bone marrow blast cell counts (R=0.6, P<0.01), blast cell distribution ratio (R=0.4, P<0.05) and lymphadenopathy (R=0.33, P<0.05). Whereas Fas expression was significantly correlated to bone marrow blast cell counts (R=0.52, P<0.01). In conclusion, assessment of Bcl-2 and Fas expression at diagnosis in acute leukemia (1) could predict responsiveness to induction chemotherapy in ALL but not in AML group but (2) could not predict patients out come both in ALL and AML groups., (Copyright 2004 Taylor and Francis Ltd.)

Risk-based treatment assignment requires the availability of prognostic factors that reliably predict clinical outcome. Junctional regions of T-cell receptor (TCR) genes provide the best tool to study clonality, lineage association and minimal residual disease (MRD) in T-ALL. In this study, we have analyzed the suitability of clonal TCR gamma and delta junctional gene rearrangement status of T-ALL patients at diagnosis as a prognostic marker for T-ALL. We studied peripheral blood samples of 50 newly diagnosed patients with T-ALL in India for incidence of clonal TCR gamma and delta junctional region gene rearrangements by PCR-coupled heteroduplex analysis. Of these, 17 T-ALL patients uniformly treated on MCP 841 protocol were followed for more than 40 months (range: 41.26-55.82 months; mean: 49.26) and their clonal TCRgammadelta genotype was correlated with clinical outcome with respect to duration of complete remission, disease-free survival (DFS) and event-free survival. We also compared the clinical and biological features of TCRgammadelta + T-ALL and TCRalphabeta + T-ALL for their relative order of significance. Thirty per cent (15 of 50) of Indian T-ALL patients exhibited clonal rearrangements of both TCR gamma and delta genes. A significant proportion of these patients (73.3%, 11 of 15 P < 0.005) showed predominant usage of VgammaI-Jgamma1.3/2.3 with Vdelta1-Jdelta1 genes. A statistically significant association of L2 and L1 FAB blast morphology with TCRgammadelta + T-ALL and TCRalphabeta + T-ALL, respectively was observed (P = 0.001 by Fisher's Exact Test). The survival rate in DFS group was higher for TCRgammadelta + T-ALL compared to TCRalphabeta + T-ALL (P = 0.1378 by Log rank test). Thus we have identified clonal TCR gamma and delta junctional gene rearrangement status of T-ALL patients at diagnosis as a prognostic marker and predictor of response to chemotherapy. In future, this may help in designing tailored and risk-adjusted (less aggressive and less toxic) therapies for subset of T-ALL patients.

Lymphocyte passage across endothelium into lymph nodes and Peyer's patches is a multistep process that involves selectin-supported rolling, followed by a triggering event, and then firm integrin-mediated adhesion. The combined actions of adhesion molecules and chemokines largely determine the migratory behavior of lymphocytes. Chemokines are known to mediate their effects through 7 transmembrane-domain G-protein-coupled receptors. Here, we review the role of chemokines and their receptors in lymphocyte's migration into lymphoid organs.

Here we describe two Caucasian brothers who developed adult T-cell leukemia/lymphoma (ATLL), within a short period of time. These two patients have never left Argentina. Their parents are dead and according to the family history it is possible that the mother may have been affected by spastic paraparesis. The daughters reported that their mother had suffered from increasing difficulty in walking for many years which finally made it impossible for to her walk. There are no other data to support the presumptive diagnosis. One of the patients presented with acute disease while the other had a lymphoma type disorder. Both were positive for HTLV 1. The first patient died with disease progression ten months after diagnosis and the second is in partial remission 13 months after diagnosis. Immunophenotyping showed CD4+, CD5+, CD3+, CD2+, CD8 (-). Two asymptomatic brothers with positive HTLV 1 serology were detected. This is the first family case that has been reported in Argentina.

T-cell acute lymphoblastic leukemia (T-ALL) is a clonal lymphoid malignancy and junctional sequences of rearranged T-cell receptor (TCR) represent the best suitable marker to study clonality in these patients. A sensitive, non-radioactive, and rapid approach of PCR coupled with heteroduplex analysis was used to analyse clonality of TCR gamma and delta gene rearrangements in 26 Indian T-ALL patients. Amongst TCR gamma gene family, VgammaI-Jgamma1.3/2.3 sequences were most utilized (53.9%) while from TCRdelta repertoire Vdelta1-Jdelta1 sequences were preferentially rearranged (23.1%) in these patients. 19.2% of Indian T-ALL patients demonstrated both clonal TCR gamma and delta gene rearrangements along with surface expression of TCRgammadelta. Although the majority of T-ALL patients showed surface expression of TCRalphabeta, the small fraction (19.2%) of TCRgammadelta+ T-ALL represent a distinct subgroup which needs further evaluation.

An 84-year-old patient with adult T cell leukemia lymphoma (ATLL) developed diarrhea on day 5 of chemotherapy and was diagnosed with cytomegalovirus (CMV) colitis. Sigmoidoscopy revealed multiple superficial erosions surrounded by a flare. Computed tomography (CT) and ultrasonogram of the abdomen revealed marked thickening of the colonic mucosa. There were 186 CMV antigen-positive leukocytes per 31,000 white blood cells (WBC). A colonic biopsy specimen showed typical CMV nuclear inclusions. Immunohistological study of the specimen was positive for CMV antigen. Administration of ganciclovir (DHPG) 500 mg/day for 14 days improved the diarrhea and other symptoms. On day 30 of the chemotherapy, the patient developed diarrhea again but was diagnosed with pseudomembranous colitis instead of CMV colitis. At that time, CMV antigenemia and a histologic study for CMV were negative. The stool was positive for Clostridium difficile toxin antigen. ATLL patients are believed to be immunocompromised hosts and often develop opportunistic infections such as CMV infection. Most suffer from CMV pneumonia at the end of their course of therapy. Few gastrointestinal (GI) CMV infections are seen in ATLL patients and details of CMV colitis have never been reported. When an ATLL patient develops diarrhea that barely responds to conventional therapy, CMV colitis and pseudomembranous colitis should be listed in the differential diagnosis.

The less differentiated stage (CD10-) of B-lineage acute lymphoblastic leukaemia (ALL) described as preB1-ALL in the GEIL nomenclature, accounts for less than 10% of ALL. It is classically considered to be associated with translocation (4;11)(q21;q23), and to have a poor prognosis. We report an extensive immunophenotypic, genomic and clinical study of a series of 64 preB-1 ALL patients, representing 6.3% of a cohort of consecutive ALLs. The engagement of preB1-ALL cells in the B-lineage was confirmed by their B-lineage score, equal to or higher than 2. In addition, more than 90% of the cases tested showed rearranged IGH genes. Translocation (4;11) was the most frequent karyotypic anomaly seen, but only accounted for 24% of the preB1-ALL cases tested. Expression of the myeloid associated antigen CD15 was also found with high incidence in this subset. Clinical and biological features at presentation showed more significant differences between preB1- and T-ALL than between preB1- and preB2-ALL (CD10+). However, outcome characteristics of the 22 children with preB1-ALL confirmed the worse prognosis of this entity.

We describe the clinical and pathological features of 23 Afro-Caribbean patients with adult T-cell leukaemia/lymphoma admitted to the Queen Elizabeth Hospital, Barbados over a 5 year period. There were 9 males and 14 females, with a median age of 38 years (range 14-84). Twelve had acute leukaemia, 10 lymphoma (including 4 with solitary extra nodal lesions) and 1 smouldering subtype. Two patients had a past history of tropical spastic paraparesis/HTLV I associated myelopathy (TSP/HAM). The prognosis was poor, with only 3 complete responses to chemotherapy (CHOP) lasting from 9 to 36 months. We conclude that ATLL in Barbados is similar to the disease in the other Caribbean islands and Japan, except that in Barbados the age of onset is over a decade younger than in Japan.

The prevalence of humoral immune dysfunction has not been defined in a large series of patients with T-cell large granular lymphocyte leukemia (T-LGL) confirmed to be clonal by T-cell receptor analysis. Therefore we evaluated the presence of multiple autoantibodies in 27 patients with this disease. Humoral immune abnormalities included: rheumatoid factor (RF) (15/27 patients), antinuclear antibody (ANA) (13/27 patients), polyclonal hypergammaglobulinemia (15/24 patients), elevated serum immunoglobulins (17/26 patients), immune complex formation (18/25 patients), elevated beta-2 microglobulin (13/18 patients) and neutrophil-reactive IgG (18/20 patients). Disease manifestations in these patients were due to complications of cytopenia or autoimmune abnormalities. Infection was a common finding (21/27 patients) and likely reflected their neutropenia. Rheumatoid arthritis (11/27 patients), anemia (12/27 patients) and thrombocytopenia (10/27 patients) were less common but still frequently observed. This study demonstrates the presence of multiple autoantibodies in a large series of patients with documented clonal T-LGL proliferations.

In this review we present our data concerning T-cell receptor (TCR) delta gene rearrangements in acute myeloid leukemia with coexpression of T-lymphoid features (CD2/CD4/CD7; Ly+ AML). We found a correlation between TCR delta gene rearrangements and coexpression of these T-lymphoid features. Ten of 66 Ly+ AML and only one of 44 AML cases without this coexpression exhibited TCR delta gene rearrangements (p = .028). In contrast, no correlation was observed between terminal deoxynucleotidyl transferase (TdT) expression and the occurrence of TCR delta gene rearrangements in AML. Rearrangements were found in two of 25 AML with and seven of 71 AML cases without TdT expression. Interestingly, nucleotide sequencing of junctional sites revealed up to 36 N-nucleotides in cases without or with only weak TdT expression indicating downregulation of TdT expression after the TCR rearrangement took place. Complete V delta 1J delta 1 and incomplete D delta 2J delta 1 gene rearrangements were observed most frequently in Ly+ AML. These recombination patterns were similar to patterns observed in acute T-lymphoblastic leukemia with coexpression of myeloid features (My+ T-ALL) suggesting transformation of a common myeloid/T-lymphoid progenitor cell in these cases.

Our previous study showed that thyroid non-Hodgkin's lymphoma (TL) in an adult T-cell leukemia/lymphoma (ATL) non-endemic area were exclusively B-cell derived. The present study was carried out to examine whether TL in an ATL endemic area are also exclusively of B-cell type. Eight cases with TL admitted to the hospital situated in an ATL endemic area were studied: they were all female with an age range from 50 to 75 (median 67) years. Histologically four of the eight cases showed a follicular pattern. Immunophenotypic study revealed all but one case to be of B-cell nature: CD3-, 4-, 8-, 20+, 22+, 45RA+, 45RO-, L22-, L24+/-, L28+. Neoplastic cells in one case with the histology of diffuse large cell lymphoma showed a CD3+, 4+, 8-, 20-, 22-, 45RA-, 45RO+/-, L22-, L24-, L28-, indicating a helper T-cell phenotype. Genotypic study showed rearrangement of T-cell beta-chain receptor in this case. This case also had antibodies against HTLV-1 in the serum. This case shows that it is also possible to develop T-cell TL in an endemic ATL area.

Adult T-cell leukemia/lymphoma (ATLL) remains an uncommon disorder outside well-defined risk groups. We describe the case of an Iranian woman, who presented with isolated meningeal relapse of diffuse large-cell lymphoma. The malignant cells coexpressed CD4 and CD8 and HTLV-1 seropositivity was confirmed. Despite combination chemotherapy disseminated lymphoma developed. Preterminally the characteristic features of ATLL were noted; hypercalcemia, with normal parathyroid hormone-related protein and vitamin D levels, and peripheral blood leukemic involvement.

We describe here a case of T-cell lymphocytic leukemia (T-CLL) which coexpressed CD4 and CD45RA cell-surface antigens and functioned as suppressor inducer cells. The patient, an 81 year-old man, had massive generalized lymphadenopathy. His hemoglobin was 9.4g/dl, the platelet count 94,000, and the WBC was 895,000/microliters with 98% abnormal lymphoid cells. He had massive hepatosplenomegaly. Serum LDH was elevated to 3,990 u/l. The T-CLL cells coexpressed antigens detected by MAbs CD2, CD3, CD4, CD5, Ti(TcR alpha/beta; WT31) CD45 and CD45RA, but did not express any other antigens including CD1, CD8, CD29, and TCR gamma/delta, Ti gamma A and TQ-1. The cell-surface phenotypes of the cultured cells established by utilizing recombinant interleukin 2 were basically the same as those of the uncultured peripheral blood lymphoid cells. Both the peripheral blood and cultured cells clearly showed gene rearrangement for T cell receptors, TcR beta and TcR gamma. No association with human T-cell leukemia virus-1 (HTLV-1) was found by means of electron microscopic studies or the application of MAbs to p19 and p24 of HTLV-1. No anti-HTLV-1 antibody was detected. By the means of two color fluorescence, it was clearly demonstrated that the leukemic cells possessing CD4 in the peripheral blood and cell cultures coexpressed CD45RA, but did not express either CD29 or TQ-1. In vitro immunoglobulin synthesis by normal T and B cells was remarkably reduced in the presence of CD8+ T and leukemic cells. This suggests suppressor inducer T cell activity for the leukemic cells.(ABSTRACT TRUNCATED AT 250 WORDS)

The immunophenotype of 304 adult lymphoblastic leukemias (> 18 years) diagnosed on the basis of the FAB criteria was determined at the time of diagnosis using a panel of monoclonal antibodies. The series comprised cases diagnosed and immunophenotyped in 43 Italian centers (GIMEMA Cooperative Group) between April 1988 and June 1991. The immunophenotypic characterization consisted of two consecutive steps. The initial screening was based on the reactivity for TdT, HLA-Dr, CD7, CD10, CD13, CD19, CD24, CD33 and CD41. According to the results obtained, the second level of investigation assessed the positivity for intra cytoplasmic (Cy) Ig, CD1a, CD2, CD3, CD4, CD5, CD8 and CD20. Based on the hierarchical expression of the different B- and T-cell related antigens, each case was assigned to a given differentiation stage. B-lineage ALL were classified in five subgroups (B0-B4) and T-lineage ALL in four subgroups (T0-T3). Cases in which the blasts were lymphoid according to the FAB criteria, but expressed myeloid antigens in association with B- and T-lymphoid markers were defined as hybrid leukemias. As expected, CD10+ cases (B2-B3) were the most frequent within the B-lineage ALL (83.2% of cases). CyIg+ (B3) accounted for about 20% of CD10+ ALL. Twenty eight cases (13.4%) were at a pre-cALL stage (B0-B1) and of these, 8 (3.8% of the total series) were positive only for TdT and HLA-Dr (B0). Intermediate and mature thymic phenotypes (T2-T3) were predominant within the T-ALL (67.2%) groups. Five cases, were positive only for TdT and CD7 (CD5+), and classified as T0. 9.2% of cases fulfilled the definition of hybrid leukemia, largely in view of the co-expression of B-lymphoid and myeloid markers.(ABSTRACT TRUNCATED AT 250 WORDS)