Systemic (nodal) anaplastic large cell lymphoma (ALCL) is a subgroup of T-cell non-Hodgkin’s lymphomas with a relatively favorable clinical outcome. Part of systemic ALCLs harbor a genetic aberration (usually the t(2;5)(p23;q35) translocation) containing the anaplastic lymphoma kinase (ALK) gene at 2p23, which results in aberrant expression of the ALK protein. Recently, we have shown that the presence of high percentages of activated cytotoxic T lymphocytes (CTLs) in tumor biopsy specimens of Hodgkin’s disease (HD) is associated with a poor prognosis. In the present study, we investigated the prognostic value of percentages of activated CTLs in combination with ALK expression in primary nodal ALCL. Primary nodal biopsies of 42 patients with ALCL were investigated for the percentage of activated CTLs (quantified using Q-PRODIT) and the expression of ALK by immunohistochemistry using monoclonal antibodies (MoAbs) directed against T-cell antigen granzyme B (GrB) and ALK, respectively. These parameters were evaluated for their predictive value regarding progression-free and overall survival time. The presence of a high percentage of activated CTLs (ie, ≥15%) was found to be an unfavorable prognostic marker. In combination with a lack of ALK expression, it was possible to identify a group of patients with a very poor prognosis. In this group, 13 of 16 patients died within 2 years as a result of the disease. Of the remaining 26 patients, only three (all ALK negative) died (P < .0001). Furthermore, the percentage of activated CTLs combined with ALK status appeared to be of stronger prognostic value than the International Prognostic Index (IPI). We conclude that a high percentage of activated CTLs present in biopsy material of patients with primary nodal ALCL is a strong indicator for an unfavorable clinical outcome. The combination of ALK expression and percentage of activated CTLs appears to be more sensitive than the IPI in identifying a group of patients with a highly unfavorable clinical outcome who may be eligible for alternative (high dose) therapy schemes.

ANAPLASTIC LARGE CELL lymphoma (ALCL) is a group of non-Hodgkin’s lymphomas characterized by large CD30+ cells with multiple or single prominent nucleoli and T-cell or null cell characteristics.1 Several histologic subtypes have been described, eg, common type, lymphohistiocytic, giant cell rich and small-cell variant.2 Clinically, two types can be recognized: a systemic variant originating mainly from lymph nodes with an intermediate prognosis; and a primary cutaneous variant with a very good prognosis.1,3,4 5 

In part of the nodal ALCLs the t(2;5)(p23;q35) is detected, resulting in the fusion of the nucleophosmin (NPM) gene at 5q35 and the anaplastic lymphoma kinase (ALK) gene at 2p23.6 This results in expression of the 80-kD chimeric protein NPM-ALK. Recently, detection of the ALK portion in formalin fixed, paraffin embedded tumor specimens by immunohistochemistry was made possible by the development of the polyclonal antibody anti-p80NPM/ALK and the monoclonal antibody (MoAb) ALK1, respectively.7,8 It was shown that expression of ALK as detected by this ALK1 MoAb correlates strongly with the presence of genetic aberrations in which the ALK locus is involved, including the t(2;5)(p23;q35).8,9Although its function is still unknown, expression of ALK and/or presence of the t(2;5) was found by several investigators to be related to a more favorable clinical outcome10-13; ALK positive cases showing an 80% 5-year surivival rate, as compared with a rate of 30% for ALK negative cases.13 

One of the issues to be resolved in the pathogenesis of lymphomas is the fact that tumor cells apparently are not effectively killed by the host’s immune system. The presence of many reactive lymphocytes surrounding the tumor cells in several types of lymphomas (especially in Hodgkin’s disease [HD] and ALCL) suggests that the neoplastic cells are able to elicit an immune response, but that evasion of this immune response is an important pathogenic factor.

Although ALCL and HD are considered to be separate clinicopathologic entities, they have, besides CD30 expression, many morphologic features in common and have a similar bimodal age distribution.1Recently, we and others have shown that in HD different immune escape mechanisms may be involved: downregulation of major histocompatability complex (MHC)-I expression by the tumor cells,14-16 expression of immunomodulatory cytokines such as interleukin-10 (IL-10) by the tumor cells inducing a local T-cell anergy,17-19 and intrinsic resistance of the tumor cells to apoptosis. The latter notion arose from our observation that HD patients with tumor biopsies harboring high percentages of activated cytotoxic T lymphocytes (CTLs), as demonstrated by the presence of granzyme B+ cells, have a far worse prognosis as compared with patients with low percentages of activated CTLs.20 We postulated that one of the possibilities was that in cases with many activated CTLs, this continuous immunogenic pressure selects for tumor cells that are best equipped to resist or inhibit CTL-mediated killing. This acquired resistance to CTL-mediated cytotoxicity might also result in resistance to therapy-induced apoptosis, thus explaining the poor treatment outcome. Indeed, we could show that, to a certain extent, in HD cases with high percentages of activated CTLs, the neoplastic cells expressed the apoptosis inhibiting gene bcl-2, in contrast to HD cases with low percentages of activated CTLs.21 

In the present study, we investigated whether the presence of high percentages of activated CTLs in the diagnostic biopsies of patients with primary nodal ALCL is related to poor clinical outcome. Because ALK expression is a strong prognostic marker in ALCL, this was done in relation to ALK expression. Furthermore, we compared its prognostic value with that of the International Prognostic Index (IPI).

Patients.

Patients with primary nodal ALCL (n = 42) were selected from the files of the Comprehensive Cancer Center Amsterdam (diagnosed between 1985 and 1997) and the Department of Pathology of the St. Elisabeth Hospital, Tilburg, The Netherlands (diagnosed between 1991 and 1994). If during this period a patient presented with recurrent ALCL, the lymph node biopsy was retrieved on which the initial diagnosis of ALCL was made. In our group, one primary tumor was retrieved in this way. Cases were classified according to the Revised European-American Classification of Lymphoid Neoplasms1 and subtyped as described by Benharroch et al.2 Staging at first presentation was determined by physical examination, full blood count, serum lactate dehydrogenase (LDH) concentration, bone marrow aspirate and biopsy, and radiologic imaging of chest and abdomen. Patient and tumor characteristics are summarized in Tables 1 and 2.

Detection of activated cytotoxic T cells.

At present, accurate detection of cytotoxic cells is possible using MoAbs, which react specifically with granzyme B (GrB)22,23and T-cell intracytoplasmic antigen (TIA-1).24 GrB is exclusively expressed in the activated form of CTLs, whereas TIA-1 expression is found in both resting and activated CTLs.25Upon activation, CTLs acquire cytotoxic granules in their cytoplasm. These granules contain, among other, the pore forming protein “perforin” and a family of highly homologous serine proteases, one of them being granzyme B,26-29which is involved in target cell DNA fragmentation and apoptosis. MoAb GrB7 was raised against recombinant human granzyme B protein.22 This antibody detects activated CTLs and natural killer (NK) cells in routinely formalin fixed, paraffin embedded tissue sections by immunohistochemistry.

Detection of both GrB and TIA-1 was performed as described previously, using a three-step staining technique.20,23,24 Moreover, to identify the nature of the GrB+ cells, double-stainings were performed for GrB and CD8 or CD3, as described previously.14 

Quantification of the percentage of GrB+ and TIA-1+ CTLs in the reactive infiltrate was performed using a commercially available interactive video overlay-based measuring system (Q-PRODIT; Leica, Cambridge, UK), as described previously.14 20 Per tumor slide, 100 to 150 fields of vision were randomly selected using an automatic scanning stage. Numbers of GrB+ and TIA-1+ lymphocytes were expressed as percentages of all lymphocytes present in a tissue section as judged by morphology. In cases where the activated CTLs were difficult to distinguish from neoplastic cells with a cytotoxic phenotype (n = 4), scoring of activated CTLs was performed with the aid of sections double-stained for GrB and CD8, which helped to differentiate between reactive lymphocytes and neoplastic cells, as the latter were CD8.

Detection of ALK positive cases.

Expression of ALK was detected in biopsy specimens by immunohistochemistry using the MoAb ALK1, as described previously,8 with minor modifications. Slides were incubated overnight using a 1:75 dilution, and staining was enhanced by the catalyzed reporter deposition (CARD) method, which amplifies biotinylated sites.30 Cases were considered positive if tumor cells showed positive labelling, irrespective of their number.

Analysis of clinical data.

For each patient, the following characteristics were noted from the medical records: age at diagnosis, sex, Ann Arbor stage at presentation, the presence or absence of B symptoms, erythrocyte sedimentation rate (ESR), serum LDH concentration, therapy, response, the occurrence of relapses, and cause of death. Performance status was assessed according to the Eastern Cooperative Oncology Group (ECOG) scale (0 to 4). For each patient, the IPI was determined as described previously.31 The median follow-up time was 25 months (range, 0 to 207 months). Survival time was measured from time of initial diagnosis until death due to ALCL or until end of follow-up. Patients who died of causes unrelated to the disease were censored at the time of death. Progression-free survival time was measured from time of initial diagnosis until time of disease relapse. Patients who did not enter complete remission were assigned a progression-free survival time of zero in the analysis.

Statistical methods.

Survival curves were constructed with the Kaplan-Meier method. Differences between the curves were analyzed using the Log-rank test. Multivariate analysis was performed using the Cox-proportional hazards model32 (enter and remove limits 0.1). Qualitative variables were analyzed by Pearson χ2 test or by the Kruskal-Wallis test, when appropriate. All P values are based on two-tailed statistical analysis. P values below .05 were considered significant. All analyses were performed using the SPSS statistical software (SPSS Inc, Chicago, IL).

Patient characteristics.

Age distribution showed a bimodal pattern, as has been described for ALCL,1 with one peak between 20 and 30 years and another between 60 and 70 years (Fig 1). ALK expression was found in 31% of all cases (13 of 42) and showed a predilection for the younger age groups (Fig 1 and Table 1). About half of the patients presented with stage III or IV disease, showing either multiple organ involvement or bone marrow dissemination.

Fig. 1.

ALK expression in patients with primary nodal ALCL in relation to age.

Fig. 1.

ALK expression in patients with primary nodal ALCL in relation to age.

Close modal

With the exception of two cases, all patients received comparable polychemotherapy, consisting of CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) regimens or variants, some receiving involved field radiation. One patient (no. 1) died before therapy could be administered; the other (no. 3) declined therapy on personal grounds. In 33 of 42 cases (78.5%), complete remission was achieved; of these, however, 12 patients (36%) experienced a relapse, with a median progression-free survival time of 9.5 months (range, 2 to 105 months).

Analysis of overall survival time showed that the IPI has a strong prognostic value (P < .001) (Fig2A). This is in line with previous studies.5,33 34 As expected, ALK expression defined a group with favorable clinical outcome: none of 13 patients with ALK positive ALCL died, whereas 16 of 29 ALK negative patients died as a result of the disease (P < .01) (Fig 2B).

Fig. 2.

(A) Comparison of overall survival time according to IPI. (B) Comparison of overall survival time, according to ALK status.

Fig. 2.

(A) Comparison of overall survival time according to IPI. (B) Comparison of overall survival time, according to ALK status.

Close modal
Tumor characteristics and GrB expression.

Neoplastic cells showed CD30 expression and either a T-cell or null-cell phenotype, as defined by the REAL classification.1 Most cases (30 of 42, 71%) belonged to the common type of ALCL, whereas eight cases (19%) were considered lymphohistiocytic type, one case (2%) as mixed (lymphohistiocytic and giant cell rich), and the remaining three (7%) as giant cell rich variant.2 

GrB expression by tumor cells was found in 23 of 42 cases (55%), with the percentage of GrB+ tumor cells ranging from a few to more than 90% of tumor cells (Table 1). In two additional cases, there was TIA-1, but no GrB expression (data not shown).

In all cases tested, GrB+ reactive lymphocytes were found interspersed between the tumor cells and displaying a granular cytoplasmic staining pattern, which reflects the granular localization of GrB (see Fig 3A and B). Numbers of GrB+ CTLs ranged between 1% and 62% of reactive lymphocytes, with approximately half of the patients having ≥15% GrB+ CTLs (n = 21).

Fig. 3.

Detection of activated CTLs. (A) Biopsy specimen of an ALCL patient with ≥ 15% activated CTLs, presenting with stage 1 disease who died 13 months later as a result of the disease. Brown cytoplasmic staining indicates GrB expression. Tumor cells are negative for GrB. (B) Biopsy specimen of an ALCL patient with a cytotoxic phenotype of the tumor cells and ≥ 15% activated CTLs. Both GrB+ tumor cells (arrowheads) and activated CTLs (thick arrows) show brown cytoplasmic staining; thin arrow indicates GrB reactive lymphocytes. (C) Double-staining for CD8 and GrB in a biopsy specimen of an ALCL patient. The majority of activated CTLs express both CD8 (brown membranous staining) and GrB (black cytoplasmic staining). Tumor cells are CD8 and GrB. (D) Double-staining for CD8 and GrB in a biopsy specimen of an ALCL patient with cytotoxic phenotype of the tumor cells. Tumor cells (arrowheads) show expression of GrB (black cytoplasmic staining), but not CD8, whereas activated CTLs (thick arrows) show expression of both GrB (black cytoplasmic staining) and CD8 (brown membranous staining).

Fig. 3.

Detection of activated CTLs. (A) Biopsy specimen of an ALCL patient with ≥ 15% activated CTLs, presenting with stage 1 disease who died 13 months later as a result of the disease. Brown cytoplasmic staining indicates GrB expression. Tumor cells are negative for GrB. (B) Biopsy specimen of an ALCL patient with a cytotoxic phenotype of the tumor cells and ≥ 15% activated CTLs. Both GrB+ tumor cells (arrowheads) and activated CTLs (thick arrows) show brown cytoplasmic staining; thin arrow indicates GrB reactive lymphocytes. (C) Double-staining for CD8 and GrB in a biopsy specimen of an ALCL patient. The majority of activated CTLs express both CD8 (brown membranous staining) and GrB (black cytoplasmic staining). Tumor cells are CD8 and GrB. (D) Double-staining for CD8 and GrB in a biopsy specimen of an ALCL patient with cytotoxic phenotype of the tumor cells. Tumor cells (arrowheads) show expression of GrB (black cytoplasmic staining), but not CD8, whereas activated CTLs (thick arrows) show expression of both GrB (black cytoplasmic staining) and CD8 (brown membranous staining).

Close modal

Double-staining showed that the large majority of GrB+reactive lymphocytes are also positive for CD3 and CD8 and are thus in majority activated CTLs. In all cases, except one, the tumor cells were found to be negative for CD8 (Table 1). This predominantly CD8 phenotype of ALCL has been demonstrated before by us and other groups.35-37 Thus, double-stainings helped to differentiate between (GrB+/CD8+) reactive lymphocytes and (GrB+/CD8) tumor cells and were used as an aid in quantifying activated CTLs in cases where it was difficult to distinguish tumor cells from reactive lymphocytes (Fig3C and D). In our study, this was the case in four lymphomas, all ALK positive (Table 2, cases 30, 32, 36, and 38).

Prognostic value of percentage activated CTLs.

The influence of the percentage of activated CTLs on overall survival time was estimated by Cox regression analysis; the prognosis declined with increasing percentages of activated CTLs (see Fig 4).

Fig. 4.

Diagram depicting the relative risk (RR) for a fatal outcome of ALCL as a function of the percentage of activated CTLs (Cox regression).

Fig. 4.

Diagram depicting the relative risk (RR) for a fatal outcome of ALCL as a function of the percentage of activated CTLs (Cox regression).

Close modal

If patients were divided into a group with ≥15% and <15% activated CTLs (the threshold leading to the lowest P value), the presence of ≥15% activated CTLs defined a group of patients with an unfavorable prognosis: 13 of 21 patients with ≥15% activated CTLs died during the follow-up period compared with three of 21 patients with <15% activated CTLs (P < .001) (Fig 5A).

Fig. 5.

(A) Comparison of overall survival time according to percentage activated CTLs. (B) Comparison of overall survival time according to percentage activated CTLs combined with ALK status. (C) Comparison of progression-free survival time according to percentage activated CTLs combined with ALK status.

Fig. 5.

(A) Comparison of overall survival time according to percentage activated CTLs. (B) Comparison of overall survival time according to percentage activated CTLs combined with ALK status. (C) Comparison of progression-free survival time according to percentage activated CTLs combined with ALK status.

Close modal

The percentage of TIA-1+ CTLs (entered as a continuous variable) was not related to progression-free and overall survival time, as estimated by Cox regression analysis.

Multivariate analysis of biological and clinical parameters.

As shown in Table 3, other factors than those mentioned until now were related to survival in univariate analysis: presence of B symptoms, LDH level, and performance status. A multivariate Cox regression analysis was performed using the factors listed in Table 3. Of these, percentage of activated CTLs (P< .001), ALK expression (P < .001) and the IPI (P< .0001) remained independently significant as prognostic markers of overall survival. The other included variables (presence of B symptoms, age, stage, number of extranodal sites, LDH level, and performance status) gave no additional prognostic information.

Prognostic value of percentage of activated CTLs combined with ALK expression.

The two variables, percentage of activated CTLs and ALK expression, were combined (see Table 4). In ALK negative cases, the presence of ≥15% activated CTLs defined a group with a very poor 2-year survival of less than 20%, as compared with ALK negative patients with <15% activated CTLs, of whom more than 80% were still alive after 2 years (P < .0001, Fig 5B). Similar results were obtained for progression-free survival time (P < .0001, see Fig 5C).

Comparison of the prognostic value of percentages activated CTLs/ALK status with the IPI.

As shown above, both indices (percentages of activated CTLs/ALK status and the IPI) were independent, strong prognostic markers in a univariate analysis of overall survival time. In retrospect, both prognostic markers identify largely the same group of patients (see Table 1). However, in a second multivariate analysis of overall survival time using the Cox-proportional hazards model, the percentage of activated CTLs combined with ALK status was a stronger prognostic marker than the IPI. This combination identified six patients who died of the disease within 2 years, although they were at low or low-intermediate risk according to the IPI (nos. 5, 9-13). Using this combined percentage of activated CTLs and ALK status index, only two patients with rapid fatal disease progression were missed (nos. 17 and 18). In contrast to the IPI, our index was also able to identify patients with poor prognosis presenting with low stage disease (nos. 11 through 13).

Thus, in this study, a high percentage of activated CTLs combined with negative ALK status seems to be more sensitive as a marker of poor prognosis in nodal ALCL than the high risk or high-intermediate risk categories of the IPI.

In this study, we have shown that the percentage of activated (GrB+) CTLs is a strong prognostic marker in patients with primary nodal ALCL. The same effect has been shown for percentages of activated CTLs in HD.20 Furthermore, we have shown that the expression of ALK is related to a favorable clinical outcome, as was also shown by previous studies.10-13 By combining percentage of activated CTLs with ALK status, it was possible (retrospectively) to accurately identify a group of patients who run a very high risk of dying within 2 years as a result of the disease. In this group, 13 of 16 patients died. In a multivariate analysis of overall survival time, the combination of percentage of activated CTLs and ALK status appeared to be a better prognostic marker than the IPI.

The IPI and other clinical risk factors are well established as prognostic markers in ALCL. In this study, the IPI and our index (percentage activated CTLs/ALK status) identify largely the same group of patients. However, although the IPI is helpful in recognizing most patients who will fail to respond well to therapy, some poorly responding patients are not identified (see Table 1, cases 5 and 9 through 13). Our findings suggest that a biological prognostic marker, as is the percentage of activated CTLs in combination with ALK status, is at least as strong and probably more sensitive in identifying these patients than established clinical markers as combined in the IPI. As such, it may be very helpful in deciding to apply alternative treatment modalities.

However, some caution has to be expressed. Because our study was performed on a relatively small number of patients, separate studies involving larger numbers are indicated to confirm the predictive value of our index.

In those cases where a high percentage of tumor cells show a cytotoxic phenotype, distinction between activated CTLs and tumor cells can be difficult. In our study, this was encountered in four cases, all ALK positive (Table 2, cases 30, 32, 36, and 38). However, double-staining for CD8 and GrB (Fig 3C and D) in these four cases helped to differentiate between activated CTLs and neoplastic cells, as tumor cells did not show CD8 expression (Table 2).

Two previous studies on ALCL with the MoAb ALK1 have shown ALK expression in 39 of 73 (53%) and 13 of 30 (43%) cases, respectively.8,9 The fact that we found less ALK positive cases (31%) is probably due to the relatively high number of elderly patients as compared with the above-mentioned studies. However, our patient group showed a pattern of age distribution consistent with the literature1 and confirmed previous studies with regard to prognostic significance of the IPI and ALK status.5,10-13,33 34 ALK positive ALCL has been uniformly shown to be related to a good prognosis. Thus, the relevance of our study lies in providing a prognostic marker for the ALK negative ALCL, which has not been described in the literature before.

The question remains why primary nodal ALCL patients with a high percentage of activated CTLs and lack of ALK expression show such a highly unfavorable clinical outcome (Fig 5B and C). The following explanations can be given.

(1) Assuming that CTLs are directed against the tumor cells, it is conceivable that in cases with many activated CTLs, only those tumor cells will survive that are best equipped to resist or inhibit CTL-mediated apoptosis. The poor clinical outcome in patients with a high percentage of activated CTLs may then be explained by assuming that resistance to CTL-induced apoptosis also results in resistance to therapy-induced apoptosis due to blockade of the final common apoptosis pathway. Indeed, several independent routes to apoptosis appear to converge on a final common pathway.38,39 CTL-mediated apoptosis is achieved by at least two pathways: the function of perforins and granzymes26-29 and activation of Fas (CD95/APO-1) on target cells,40-42 which induces apoptosis by activation of downstream “caspases”.43 The Fas system was shown also to be involved in drug-induced apoptosis in leukemia cells.44 The downstream antiapoptosis gene, bcl-2, has been shown to reduce sensitivity to both chemotherapy and CTL-induced apoptosis,39,45-47 in the latter case by blocking the apoptosis pathway before caspase activation.48Indeed, in a recent study on HD by our group, cases with a high percentage of activated CTLs (predisposing for poor prognosis) showed bcl-2 expression by tumor cells.21 

(2) A possible immune escape mechanism, other than apoptosis resistance, is downregulation of MHC class I expression on the membrane of the tumor cells, preventing recognition of tumor-associated antigens by CTLs. However, in our study, no downregulation of MHC-I expression was found (data not shown).

In addition, tumor cells might circumvent CTL-mediated killing through induction of a local T-cell anergy by expressing certain cytokines. For instance, IL-10 (which has been shown to have direct suppressive effects on cytotoxic T lymphocytes)17-19,49,50 was recently demonstrated in ALCL.51 

Finally, tumor cells might escape CTL-mediated killing by neutralizing the function of granzymes. Recently, a serine protease inhibitor (serpin) designated PI-9 was cloned and shown to be a potent inhibitor of GrB-mediated apoptosis.52 Expression of such inhibitory proteins by the tumor cells would also render them resistant to CTL-mediated lysis. However, these mechanisms of immune evasion (MHC I downregulation, local T-cell anergy, and expression of serpins by tumor cells) cannot account for the poor response to therapy.

We conclude that a high percentage of activated CTLs present in biopsy material of patients with ALK negative ALCL is a strong indicator for an unfavorable clinical outcome. In combination with negative ALK status, the presence of high numbers of activated CTLs is a very strong prognostic marker, even more sensitive than the IPI, in identifying a group of ALCL patients with a highly unfavorable clinical outcome. We advise studies with larger numbers of cases to validate the predictive value of our index as described here. Furthermore, studies are indicated to elucidate the putative role of apoptosis resistance as a pathogenic mechanism in ALCL.

The authors thank the following persons for their help in collecting tumor material and clinical data: Dr P. van Heerde, Dr J.J.A.M. ten Velden, Dr W.S. Kwee, Dr A.P. Willig, and Dr H. van den Berg. We thank Elly Fieret for her excellent technical assistance.

R.L.T.B. and D.F.D. contributed equally to this study.

The publication costs of this article were defrayed in part by page charge payment. This article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C. section 1734 solely to indicate this fact.

1
Harris
NL
Jaffe
ES
Stein
H
Banks
PM
Chan
JKC
Cleary
ML
Delsol
G
De Wolf-Peeters
C
Falini
B
Gatter
KC
Grogan
TM
Isaacson
PG
Knowles
DM
Mason
DY
Muller-Hermelink
HC
Pileri
SA
Piris
MA
Ralfkiaer
E
Warnke
RA
A revised European-American classification of lymphoid neoplasms: A proposal from the International Lymphoma Study Group.
Blood
84
1994
1361
2
Benharroch
D
Meguerian-Bedoyan
Z
Lamant
L
Amin
C
Brugières
L
Terrier-Lacombe
MJ
Haralambieva
E
Pulford
K
Pileri
S
Morris
SW
Mason
DY
Delsol
G
ALK-positive lymphoma: A single disease with a broad spectrum of morphology.
Blood
91
1998
2076
3
de Bruin
PC
Beljaards
RC
van Heerde
P
van der Valk
P
Noorduyn
LA
van Krieken
JHJM
Kluin-Nelemans
JC
Willemze
R
Meijer
CJLM
Differences in clinical behaviour and immunophenotype between primary cutaneous and primary nodal anaplastic large cell lymphoma of T-cell or null cell phenotype.
Histopathology
23
1993
127
4
Willemze
R
Kerl
H
Sterry
W
Berti
E
Cerroni
L
Chimenti
S
Diaz-Peréz
JL
Geerts
ML
Goos
M
Knobler
R
Ralfkiaer
E
Santucci
M
Smith
N
Wechsler
J
van Vloten
WA
Meijer
CJLM
EORTC classification for primary cutaneous lymphomas: A proposal from the Cutaneous Lymphoma Study Group of the European Organization for Research and Treatment of Cancer.
Blood
90
1997
354
5
Tilly
H
Gaulard
P
Lepage
E
Dumontet
C
Diebold
J
Plantier
I
Berger
F
Symann
M
Petrella
T
Lederlin
P
Brière
J
Primary anaplastic large-cell lymhoma in adults: Clinical presentation, immunophenotype, and outcome.
Blood
90
1997
3727
6
Morris
SW
Kirstein
MN
Valentine
MB
Dittmer
KG
Shapiro
DN
Saltman
DL
Look
AT
Fusion of a kinase gene, ALK, to a nucleolar protein gene, NPM, in non-Hodgkin’s lymphoma.
Science
263
1994
1281
7
Shiota
M
Fujimoto
J
Takenaga
M
Satoh
H
Ichinoshama
R
Abe
M
Nakano
M
Yamamoto
T
Mori
S
Diagnosis of t(2;5)(p23;q35)-associated Ki-1 lymphoma with immunohistochemistry.
Blood
84
1994
3648
8
Pulford
K
Lamant
L
Morris
SW
Butler
LH
Wood
KM
Stroud
D
Delsol
G
Mason
DY
Detection of anaplastic lymphoma kinase (ALK) and nucleolar protein nucleophosmin (NPM)-ALK proteins in normal and neoplastic cells with the monoclonal antibody ALK1.
Blood
89
1997
1394
9
Pittaluga
S
Wlodarska
I
Pulford
K
Campo
E
Morris
SW
Van den Berghe
H
De Wolf-Peeters
C
The monoclonal antibody ALK1 identifies a distinct morphological subtype of anaplastic large cell lymphoma associated with 2p23/ALK rearrangements.
Am J Pathol
151
1997
343
10
Le Beau
MM
Bitter
MA
Larson
RA
Doane
LA
Ellis
ED
Franklin
WA
Rubin
CM
Kadin
ME
Vardiman
JW
The t(2;5)(p23;q35): A recurring chromosomal abnormality in Ki-1-positive large cell lymphoma.
Leukemia
3
1989
866
11
Bitter
MA
Franklin
WA
Larson
RA
McKeithan
TW
Rubin
CM
LeBeau
MM
Stephens
JK
Vardiman
JW
Morphology in Ki-1(CD30)-positive non-Hodgkin’s lymphoma is correlated with clinical features and the presence of a unique chromosomal abnormality, t(2;5)(p23;q35).
Am J Surg Pathol
14
1990
305
12
Sandlund
JT
Pui
CH
Roberts
M
Santana
VM
Morris
SW
Berard
CW
Hutchison
RE
Ribeiro
RC
Mahmoud
H
Crist
WM
Heim
M
Raimondi
SC
Clinicopathologic features and treatment outcome of children with large-cell lymphoma and the t(2;5)(p23;q35).
Blood
84
1994
2467
13
Shiota
M
Nakamura
S
Ichinoshama
R
Abe
M
Akagi
T
Takeshita
M
Mori
N
Fujimoto
J
Miyauchi
J
Mikata
A
Nanba
K
Takami
T
Yamabe
H
Takano
Y
Izumo
T
Mohri
N
Nasu
K
Satoh
H
Katano
H
Fujimoto
J
Yamamoto
T
Mori
S
Anaplastic large cell lymphomas expressing the novel chimeric protein p80 NPM/ALK: A distinct clinicopathologic entity.
Blood
86
1995
1954
14
Oudejans
JJ
Jiwa
NM
Kummer
JA
Horstman
A
Vos
W
Baak
JPA
Kluin
PM
van der Valk
P
Walboomers
JMM
Meijer
CJLM
Analysis of major histocompatibility complex class I expression in Reed-Sternberg cells in relation to the cytotoxic T-cell response in Epstein-Barr virus positive and negative Hodgkin’s disease.
Blood
87
1996
3844
15
Poppema
S
Visser
L
Absence of HLA class I expression by Reed-Sternberg cells.
Am J Pathol
145
1994
37
16
Lee
SP
Constandinou
CM
Thomas
WA
Croomcarter
D
Blake
NW
Murray
PG
Crocker
J
Rickinson
AB
Antigen presenting phenotype of Hodgkin-Reed-Sternberg cells — analysis of the HLA class I processing pathway and the effects of interleukin-10 on Epstein Barr Virus-specific cytotoxic T-cell recognition.
Blood
92
1998
1020
17
Taga
K
Tosato
G
IL-10 inhibits human T-cell proliferation and IL-2 production.
J Immunol
148
1992
1143
18
Matsuda
M
Salazar
F
Petersson
M
Masucci
G
Hansson
J
Pisa
P
Zhang
QJ
Masucci
MG
Kiessling
R
Interleukin 10 pretreatment protects target cells from tumor- and allo-specific cytotoxic T-cells and downregulates HLA class I expression.
J Exp Med
180
1994
2371
19
Ohshima
K
Suzumiya
J
Akamatu
M
Takeshita
M
Kikuchi
M
Human and viral interleukin-10 in Hodgkin’s disease, and its influence on CD4+ and CD8+ T lymphocytes.
Int J Cancer
62
1995
5
20
Oudejans
JJ
Jiwa
NM
Kummer
JA
Ossenkoppele
GJ
van Heerde
P
Baars
JW
Kluin Ph
M
Kluin-Nelemans
JC
van Diest
PJ
Middeldorp
JM
Meijer
CJLM
Activated cytotoxic T cells as prognostic marker in Hodgkin’s disease.
Blood
89
1997
1376
21
Brink
AATP
Oudejans
JJ
van den Brule
AJC
Kluin Ph
M
Horstman
A
Ossenkoppele
GJ
van Heerde
P
Jiwa
NM
Meijer
CJLM
Low p53 and high bcl-2 expression in Reed-Sternberg cells predicts poor clinical outcome of Hodgkin’s disease: Involvement of apoptosis resistance.
Mod Pathol
11
1998
376
22
Kummer
JA
Kamp
AM
van Katwijk
M
Brakenhoff
JPJ
Radosevic
K
van Leeuwen
AM
Borst
J
Verweij
CL
Hack
CE
Production and characterization of monoclonal antibodies raised against recombinant human granzymes A and B and showing cross reactions with the natural proteins.
J Immunol Methods
163
1993
77
23
Kummer
JA
Kamp
AM
Tadema
TM
Vos
W
Meijer
CJLM
Hack
E
Localization and identification of granzymes A and B expressing cells in normal human lymphoid tissue and peripheral blood.
Clin Exp Immunol
100
1995
164
24
Anderson
P
Nagler-Anderson
C
O’Brien
C
Levine
H
Watkins
S
Slayter
HS
Blue
ML
Schlossman
SF
A monoclonal antibody reactive with a 15 kDa cytoplasmic granule-associated protein defines a subpopulation of CD8+ T-lymphocytes.
J Immunol
144
1990
574
25
Anderson
P
TIA-1: Structural and functional studies on a new class of cytolytic effector molecule.
Curr Top Microbiol Immunol
198
1995
131
26
Griffiths
GM
The cell biology of CTL killing.
Curr Opin Immunol
7
1995
343
27
Podack
ER
Execution and suicide: Cytotoxic lymphocytes enforce Draconian laws through separate molecular pathways.
Curr Opin Immunol
7
1995
11
28
Shresta
S
Maclvor
DM
Heusel
JW
Russel
JH
Ley
TJ
Natural killer and lymphokine activated killer cells require granzyme B for the rapid induction of apoptosis in susceptible target cells.
Proc Natl Acad Sci USA
92
1995
5679
29
Heusel
JW
Wesselschmidt
RL
Shresta
S
Russel
JH
Ley
TJ
Cytotoxic lymphocytes require granzyme B for the rapid induction of DNA fragmentation and apoptosis in allogenic target cells.
Cell
76
1994
977
30
Bobrow
MN
Shaughnessy
KJ
Litt
GJ
Catalized reporter deposition: A novel method of signal amplification. II. Application to membrane immunoassays.
J Immunol Methods
125
1989
279
31
The International Non-Hodgkin’s Lymphoma Prognostic Factors Project
A predictive model for aggressive non-Hodgkin’s lymphoma.
N Engl J Med
329
1993
987
32
Cox
DR
Regression models and life tables.
J R Stat Soc Br
34
1972
187
33
Melnyk
A
Rodriguez
A
Pugh
WC
Cabannillas
F
Evaluation of the Revised European-American Lymphoma classification confirms the clinical relevance of immunophenotype in 560 cases of aggressive non-Hodgkin’s lymphoma.
Blood
89
1997
4514
34
Hermans
J
Krol
AD
van Groningen
K
Kluin
PM
Kluin-Nelemans
JC
Kramer
MH
Noordijk
EM
Ong
F
Wijermans
PW
International Prognostic Index for aggressive non-Hodgkin’s lymphoma is valid for all malignancy grades.
Blood
86
1995
1460
35
Kummer
JA
Vermeer
MH
Dukers
DF
Meijer
CJLM
Willemze
R
Most primary cutaneous CD30-positive lymphoproliferative disorders have a CD4-positive cytotoxic T-cell phenotype.
J Invest Dermatol
109
1997
636
36
Krenacs
L
Wellmann
A
Sorbara
L
Himmelmann
AW
Bagdi
E
Jaffe
ES
Raffeld
M
Cytotoxic cell antigen expression in anaplastic large cell lymphomas of T- and null-cell type and Hodgkin’s disease: Evidence for a distinct cellular origin.
Blood
89
1997
980
37
Foss
HD
Anagnostopoulos
I
Araujo
I
Assaf
C
Demel
G
Kummer
JA
Hummel
M
Stein
H
Anaplastic large-cell lymphomas of T-cell and null-cell phenotype express cytotoxic molecules.
Blood
88
1996
4005
38
Tu
Y
Renner
S
Xu
FH
Fleishman
A
Taylor
J
Weisz
J
Vescio
R
Rettig
M
Berenson
J
Krajweski
S
Reed
JC
Lichtenstein
A
Bcl-x expression in multiple myeloma: Possible indicator of chemoresistance.
Cancer Res
58
1998
256
39
Strasser
A
Harris
AW
Jacks
T
Cory
S
DNA damage can induce apoptosis in proliferating lymphoid cells via p53-independent mechanisms inhibitable by bcl-2.
Cell
79
1994
329
40
Lowin
B
Hahne
M
Mattmann
C
Tschopp
J
Cytolytic T cell cytotoxicity is mediated through perforin and Fas lytic pathways.
Nature
370
1994
650
41
Kägi
D
Vignaux
F
Ledermann
B
Bürki
K
Depraetere
V
Nagata
S
Hengartner
H
Golstein
P
Fas and perforin pathways as major mechanisms of T cell mediated cytotoxicity.
Science
265
1994
528
42
Plumas
J
Jacob
MC
Chaperot
L
Molens
JP
Sotto
JJ
Bensa
JC
Tumor B cells from non-Hodgkin’s lymphoma are resistant to CD95 (Fas/APO-1)-mediated apoptosis.
Blood
91
1998
2875
43
Enari
M
Hug
H
Nagata
S
Involvement of an ICE-like protease in Fas-mediated apoptosis.
Nature
375
1995
78
44
Freisen
C
Herr
I
Krammer
pH
Debatin
K
Involvement of the CD95 (APO1/Fas) receptor/ligand system in drug-induced apoptosis in leukemia cells.
Nature Med
2
1996
574
45
Yang
E
Korsmeyer
S
Molecular thanatopsis: A discourse on the bcl2 family and cell death.
Blood
88
1996
386
46
Schröter
M
Lowin
B
Borner
C
Tschopp
J
Regulation of Fas (APO-1/CD95)- and perforin-mediated lytic pathways of primary cytotoxic T lymphocytes by the protooncogene bcl-2.
Eur J Immunol
25
1995
3509
47
Nuñez
G
Merino
R
Grillot
D
González-Garcı́a
M
Bcl-2 and bcl-x: Regulatory switches for lymphoid death and survival.
Immunol Today
15
1994
582
48
Messineo
C
Hunter Jamerson
M
Hunter
E
Braziel
R
Bagg
A
Irving
SG
Cossman
J
Gene expression by single Reed-Sternberg cells: Pathways of apoptosis and activation.
Blood
91
1998
2443
49
Becker
JC
Czerny
C
Brocker
EB
Maintenance of clonal anergy by endogenously produced IL-10.
Int Immunol
6
1994
1605
50
Ding
L
Shevach
EM
IL-10 inhibits mitogen-induced T cell proliferation by selectively inhibiting macrophage co-stimulatory function.
J Immunol
148
1992
3133
51
Boulland
ML
Meignin
V
Leroy-Viard
K
Copie-Bergman
C
Brière
J
Brousse
N
Emile
JF
Joab
I
Kanavaros
P
Gaulard
P
Interleukin-10 is frequently expressed in anaplastic T-cell lymphomas. Presented at the IX Meeting European Association for Haematopathology. Leiden, The Netherlands, April 26-29
1998
25
52
Sun
JR
Bird
CH
Sutton
V
McDonald
L
Coughlin
PB
Dejong
TA
Trapani
JA
Bird
PI
A cytosolic granzyme B inhibitor related to the viral apoptotic regulator cytokine respons modifier A is present in cytotoxic lymphocytes.
J Biol Chem
271
1996
27802

Author notes

Address reprint requests to Chris J.L.M. Meijer, MD, PhD, Department of Pathology, University Hospital Vrije Universiteit, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.

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