Does the surgeon still have a role to play in the diagnosis and management of lymphomas?

<p>Abstract</p> <p>Background</p> <p>Over the course of the past 40 years, there have been a significant number of changes in the way in which lymphomatous disease is diagnosed and managed. With the advent of computed tomography, there is little role for staging laparotomy and the surgeon's role may now more diagnostic than therapeutic.</p> <p>Aims</p> <p>To review all cases of lymphoma diagnosed at a single institution in order determine the current role of the surgeon in the diagnosis and management of lymphoma.</p> <p>Patients and methods</p> <p>Computerized pathology records were reviewed for a five-year period 1996 to 2000 to determine all cases of lymph node biopsy (incisional or excisional) in which tissue was obtained as part of a planned procedure. Cases of incidental lymphadenopathy were thus excluded.</p> <p>Results</p> <p>A total of 297 biopsies were performed of which 62 (21%) yielded lymphomas. There were 22 females and 40 males with a median age of 58 years (range: 19–84 years). The lymphomas were classified as 80% non-Hodgkin's lymphoma, 18% Hodgkin's lymphoma and 2% post-transplant lymphoproliferative disorder. Diagnosis was established by general surgeons (n = 48), ENT surgeons (n = 9), radiologists (n = 4) and ophthalmic surgeons (n = 1). The distribution of excised lymph nodes was: cervical (n = 23), inguinal (n = 15), axillary (n = 11), intra-abdominal (n = 6), submandibular (n = 2), supraclavicular (n = 2), periorbital (n = 1), parotid (n = 1) and mediastinal (n = 1). Fine needle aspiration cytology had been performed prior to biopsy in only 32 (52%) cases and had suggested: lymphoma (n = 10), reactive changes (n = 13), normal (n = 5), inadequate (n = 4). The majority (78%) of cervical lymph nodes were subjected to FNAC prior to biopsy whilst this was performed in only 36% of non-cervical lymphadenopathy.</p> <p>Conclusion</p> <p>The study has shown that lymphoma is a relatively common cause of surgical lymphadenopathy. Given the limitations of FNAC, all suspicious lymph nodes should be biopsied following FNAC even if the FNAC is reported normal or demonstrating reactive changes only. With the more widespread application of molecular techniques, and the development of improved minimally-invasive procedures, percutaneous and endoscopic techniques may come to dominate, however, at present; the surgeon still has an important role to play in the diagnosis if not treatment of lymphomas.</p

T-Cell Regulation in Lepromatous Leprosy

Regulatory T (T(reg)) cells are known for their role in maintaining self-tolerance and balancing immune reactions in autoimmune diseases and chronic infections. However, regulatory mechanisms can also lead to prolonged survival of pathogens in chronic infections like leprosy and tuberculosis (TB). Despite high humoral responses against Mycobacterium leprae (M. leprae), lepromatous leprosy (LL) patients have the characteristic inability to generate T helper 1 (Th1) responses against the bacterium. In this study, we investigated the unresponsiveness to M. leprae in peripheral blood mononuclear cells (PBMC) of LL patients by analysis of IFN-γ responses to M. leprae before and after depletion of CD25(+) cells, by cell subsets analysis of PBMC and by immunohistochemistry of patients' skin lesions. Depletion of CD25(+) cells from total PBMC identified two groups of LL patients: 7/18 (38.8%) gained in vitro responsiveness towards M. leprae after depletion of CD25(+) cells, which was reversed to M. leprae-specific T-cell unresponsiveness by addition of autologous CD25(+) cells. In contrast, 11/18 (61.1%) remained anergic in the absence of CD25(+) T-cells. For both groups mitogen-induced IFN-γ was, however, not affected by depletion of CD25(+) cells. In M. leprae responding healthy controls, treated lepromatous leprosy (LL) and borderline tuberculoid leprosy (BT) patients, depletion of CD25(+) cells only slightly increased the IFN-γ response. Furthermore, cell subset analysis showed significantly higher (p = 0.02) numbers of FoxP3(+) CD8(+)CD25(+) T-cells in LL compared to BT patients, whereas confocal microscopy of skin biopsies revealed increased numbers of CD68(+)CD163(+) as well as FoxP3(+) cells in lesions of LL compared to tuberculoid and borderline tuberculoid leprosy (TT/BT) lesions. Thus, these data show that CD25(+) T(reg) cells play a role in M. leprae-Th1 unresponsiveness in LL

Gamma-delta T-cell lymphomas

Peripheral T-cell lymphomas (TCLs) are uncommon neoplasms, accounting for about 12% of all lymphoid tumors worldwide. TCLs in which γδ T-cell receptors are expressed (γδ TCLs) are extremely aggressive and rare (≤1% of lymphoid neoplasms). γδ TCLs originate from γδ T cells, a small subset of peripheral T cells with direct antigen recognition capability acting at the interface between innate and adaptive immunity. Two distinct γδ TCL entities are recognized: hepatosplenic T-cell lymphoma (HSTL) and primary cutaneous γδ T-cell lymphoma (PCGD-TCL). HSTL is a well-characterized extranodal lymphoma that has a disguised onset, secondary to intrasinusoidal infiltration of the spleen, liver and bone marrow, has a rapidly progressive course that is poorly responsive to chemotherapy, and often ensues in the setting of immune system suppression. PCGD-TCL can present with prominent epidermal involvement or with a panniculitis-like clinical picture that can be complicated by a concurrent hemophagocytic syndrome; the disease shows biological and phenotypic overlap with other extranodal γδ TCLs that involve the respiratory or gastrointestinal tract mucosa. The regular application of phenotypic and molecular techniques is crucial for the diagnosis of γδ TCLs. In this Review, we discuss the clinical and biological features, the diagnostic challenges and the therapeutic perspectives of HSTL and PCGD-TCL. © 2009 Macmillan Publishers Limited. All rights reserved