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1 From the Center for Medical Genetics and Molecular Medicine and the 2 Departments of Pathology and 3 Ophthalmology, Haukeland University Hospital, Bergen, Norway.
| Abstract |
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METHODS. Biopsy specimens from 26 patients were examined by histomorphologic and immunohistochemical analysis. Lymphomas were classified according to the Revised European-American Lymphoma Classification. Chromosomal imbalances were detected by high-resolution comparative genomic hybridization (CGH). Clinical data were obtained by retrospective evaluation of medical records.
RESULTS. Chromosomal imbalances were detected in 0 of 6 patients with idiopathic orbital inflammation, 0 of 2 with benign reactive lymphoid hyperplasia, 3 of 3 with highly malignant diffuse large B-cell lymphoma, 4 of 10 with marginal zone B-cell lymphoma, 0 of 1 with chronic lymphatic leukemia lymphoma, and 1 of 4 with immunocytoma. Among the low-grade malignancies, chromosomal imbalances were seen in 1 of 9 at stage IAE, 2 of 3 at stage IIE, and 2 of 3 at stage IVE. Chromosomal imbalances were observed in all primary tumors from the five patients that later developed recurrent disease. In 14 of 23 imbalances with intrachromosomal breaks outside the centromere region, the breaks were present at bands with known fragile sites. No chromosomal imbalances specific for orbital presentation were detected.
CONCLUSIONS. Chromosomal imbalances were seen mainly in orbital lymphomas that were either highly malignant or at an advanced stage. CGH analysis of orbital lymphomas could be prognostically relevant, but further studies are required to confirm this notion.
| Introduction |
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Cytogenetic studies of non-Hodgkin lymphomas have revealed a number of chromosomal translocations. Well-known examples include t(8;14)(q24;q32) in Burkitt lymphoma,4 t(14;18)(q32;q21) in follicle center lymphoma,5 t(11;14)(q13;q32) in mantle cell lymphoma,6 and t(3;14)(q27;q32) in DLBCLs.7 In these translocations, an oncogene (CMYC, BCL2, BCL1, and BCL6, respectively) is translocated to the vicinity of an Ig heavy-chain gene, causing an increased expression of the oncogene.
In contrast to the frequent detection of translocations, chromosomal gains or losses are less commonly seen in non-Hodgkin lymphomas with conventional karyotyping.8 A number of chromosomal imbalances have been observed, however, in lymphomas of different subtypes using comparative genomic hybridization (CGH). CGH is a genome-wide screening procedure for chromosomal gains or losses, but it does not detect balanced translocations.9 With this method, tumor DNA is used directly for analysis. No cultivation of cells is necessary, and the selection of subclones of tumor cells is therefore avoided.
Studies of chromosomal imbalances are of interest, because chromosomal gains or losses may indicate the location of oncogenes or tumor-suppressor genes, respectively. The presence of chromosomal aneuploidy in lymphomas can be important for prognosis.10 11 Although a wide range of aberrations have been observed in lymphomas, some are more frequently seen within individual subtypes, indicating that CGH analysis could be relevant for the classification of lymphomas.
Very few orbital lymphomas and no benign lymphoid lesions of the orbit have been examined for chromosomal abnormality.8 Conventional banding analysis revealed trisomy 3 and 7 in one patient with orbital mucosa-associated lymphoid tissue (MALT) lymphoma12 (in the Revised European-American Lymphoma [REAL] classification,13 MALT lymphomas are included among the MZBCLs), whereas in three other patients with MZBCLs, t(11;18)(q21;21), trisomy 3 and t(14;18)(q32;q21), and hypotetraploidy, respectively, were detected.14 Fluorescence in situ hybridization (FISH) analysis with centromere-specific probes revealed trisomy 3 in two of five and trisomy 18 in one of five cases of MALT lymphoma.15 No chromosomal abnormalities were detected in a single case of orbital MZBCL examined by CGH analysis.16
In the present study, we analyzed different lymphoid tumors of the orbit for the presence of chromosomal aberrations by comparative genomic hybridization, using both fresh-frozen and archival paraffin-embedded specimens. In addition, we examined cases of idiopathic orbital inflammation that appeared as a space-occupying mass. Such lesions are usually not included among the lymphoproliferative disorders,17 but analysis for chromosomal aneuploidy is of interest, because cytogenetic abnormalities have been described in other tumors with an inflammatory component.18
We observed a variety of chromosomal gains or losses in 8 of 18 lymphomas, whereas no abnormalities were detected in the 8 benign lesions. Except for one case, the lymphomas with chromosomal imbalances were either highly malignant or at an advanced stage. All primary tumors from the five patients in whom recurrent disease developed later showed chromosomal aberrations.
| Materials and Methods |
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Inflammatory lesions were present in six patients. Four had lymphoid infiltrates (two in the lacrimal gland, one in the posterior part of the orbit, and one in the medial part of the orbit), and two had granulomatous infiltrates (one in the lacrimal gland and one in the lower temporal part of the orbit). Reactive lymphoid hyperplasia was present in two patients.
Among the 18 patients with lymphoma, one had previously been treated for mediastinal lymphoma (patient 13), whereas primary tumors were seen in the remaining patients (Table 1) . The median follow-up time for these patients was 29 months (range, 2150 months). Three patients (patients 9, 11, and 15) died during the follow-up period of causes other than lymphoma. No lymphoma-related deaths were observed.
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light chains, and against CD3, CD5, CD20, and BCL2 in an automated
slide processing system (ChemMate; Dako, Glostrup, Denmark). All
specimens were reviewed as part of the present study, and the lymphoma
diagnoses were according to the REAL classification of lymphoid
neoplasms.13
The samples processed for CGH analysis
contained more than 50% tumor cells. The samples were coded before DNA
extraction, and the identity of the specimens remained unknown until
the CGH analysis had been completed.
DNA Extraction
DNA was isolated from fresh-frozen tissue in 14 cases and from
archival, paraffin-embedded material in 12 cases. The fresh-frozen
samples were treated with proteinase K (Qiagen, Hilden, Germany) and
DNA was isolated by phenol-chloroform extraction using standard
procedures. The paraffin-embedded material was cut into 10-µm
sections. Approximately 10 to 15 sections were deparaffinized in 2-mL
tubes (Nalge Nunc, Naperville, IL; 2 x 1.5 mL xylene for 10
minutes each and 1 x 1.5 mL 100% ethanol for 10 minutes with
centrifugation at 3500 rpm for 10 minutes; Eppendorf centrifuge;
Brinkman Instruments, Westbury, NY). After they were air dried at room
temperature, samples were suspended in 0.7 mL DNA extraction buffer
(0.15 M NaCl, 0.05 M Tris-HCl [pH 8], 0.5 mM EDTA [pH 8], 1%
sodium dodecyl sulfate, and 0.5 mg/mL proteinase K) and incubated at
58°C overnight. If digestion was not complete, additional proteinase
K was added, and the samples were incubated at 58°C for another 24
hours. DNA was then extracted by a standard phenol-chloroform procedure
until the water phase was clear. After a final extraction with
chloroform, NaCl was added to a final concentration of 0.2 M, and the
DNA was precipitated with ethanol at -20°C. The samples were
centrifuged at 14,000 rpm for 20 minutes, the pellet washed once with
70% ethanol, air dried, and then suspended in 10 mM Tris-HCl and 1 mM
EDTA [pH 8.0]. The quality and the concentration of the DNA were
determined by agarose gel electrophoresis.
Comparative Genomic Hybridization
Metaphases from normal peripheral blood lymphocytes were
prepared according to standard procedures, using phytohemagglutinin
(PHA) for stimulation of the lymphocytes and methotrexate for
synchronization of the cell cycle. Slides with metaphase spreads were
postfixed in 1% formaldehyde in phosphate-buffered saline (pH 7.4) for
5 minutes at 4°C, dehydrated in an ethanol series (70%, 85%, and
100%) and stored at -20°C before hybridization.
CGH was performed essentially as described by Kallioniemi et al.19 Normal metaphases were denatured in 70% formamide and 2x SSC (pH 7.0) for 2 minutes at 70°C and dehydrated in an ethanol series. Normal male or female DNA was used as reference DNA after labeling with Texas red-5-dUTP (NEN Life Science Products, Inc., Boston, MA) using nick translation. Tumor DNA was labeled with fluorescein-isothiocyanate (FITC)-12-dUTP (NEN Life Science Products). Genomic DNA was digested to fragment lengths of 300 to 2000 bp. Labeled test DNA (800 ng) and normal reference DNA (800 ng), together with excess unlabeled Cot-1 DNA (Gibco-BRL, Grand Island, NY), were dissolved in 10 µL 50% formamide and 10% dextran sulfate, 2x SSC (pH 7.0), denatured at 70°C for 5 minutes, and hybridized to normal lymphocyte metaphase chromosomes for 3 days. After two washes in 50% formamide and 2x SSC and one wash in 2x SSC, slides were counterstained with 4,6-diamidine-2-phenylindole in an antifade solution.
Digital Image Analysis
For CGH analysis, image capturing and processing were performed
on a digital image system (CytoVision System, ver. 2.7; High Resolution
CGH analysis; Applied Imaging, Newcastle, UK). In each case, 15 to 20
metaphases were collected using an epifluorescence microscope (Eclipse
E800; Nikon, Tokyo, Japan) and a charge-coupled device (CCD) camera
interfaced to the workstation (CytoVision Station). The green (tumor
DNA)-to-red (normal reference DNA) fluorescence ratio along the length
of chromosomes was calculated. Detection of aberrations was performed
by dynamic standard reference intervals as described by Kirchhoff et
al.20
21
Briefly, the dynamic standard reference interval
is based on an average of 17 normal cases. The mean ratio profile of
the 99.5% (paraffin-embedded specimens) or 99.9% (frozen samples)
confidence interval of each case was compared with the 99.5% or 99.9%
confidence interval, respectively, based on the normal cases. The
dynamic standard intervals are wide at regions known to produce
unreliable CGH profiles. The dynamic standard reference interval was
scaled automatically to fit each test case. To reduce the risk of
false-positive results, DNA from all tumors was hybridized twice to
both sex-matched and mismatched DNA, and only the reproducible
aberrations were included. The DNA from fresh-frozen tissue produced
narrow confidence intervals, and 99.9% confidence intervals could be
used in the analysis of these samples, thus increasing the specificity.
| Results |
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All DLBCLs were classified as highly malignant. The lowest number of chromosomal imbalances was detected in the primary tumor at stage IIIE (patient 18). The highest number of imbalances was seen in the primary tumor of patient 16. This patient developed recurrent disease in the right gluteal region 6 months after the diagnosis of the primary tumor.
| Discussion |
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To improve sensitivity, a procedure based on standard reference intervals has recently been introduced.20 In this method, the confidence interval of the CGH profile from the tumor sample is compared with that obtained from a series of samples of normal DNA. Conventional CGH has a detection limit above 10 Mb. With the high-resolution analysis, deletions in the 3- to 10-Mb range can be detected.21 The use of this procedure was necessary to detect small deletions such as 7q31 in two of the MZBCLs.
Marginal Zone B-Cell Lymphomas
Very few CGH-studies of MZBCLs have been reported. In a series of
25 cases, Dierlamm et al.16
observed chromosomal
imbalances in 80%. The disease was at stage II or more in 22 of the 25
patients. In our series, chromosomal imbalances were seen only in 40%
of the MZBCLs, but were present in three of four tumors at stage IIE or
IVE. The lower proportion of tumors with detectable chromosomal
imbalances reported in this study could have been due to the higher
number of patients with disease at stage IAE.
Some, but not all, of the abnormalities seen in our cases of MZBCL have been reported previously. Gains at 1q and 3q with minimal common regions at 1q25-q31, 3q21-q23, and 3q25-q29 are frequently detected by CGH analysis.16 Losses at 7q31 have been observed in 40% of splenic MZBCLs with PCR analysis of microsatellite markers.23 Trisomy 8 has been detected with conventional banding techniques in follicular center lymphoma,24 but has not been reported previously in MZBCLs. Gains of 2q with a break at 2q33 were seen in one recurrent case of MZBCL in the series of Dierlamm et al.16 Losses at 4p and 4q are rare observations in non-Hodgkin lymphomas.8 Loss of chromosome 14 has been detected by CGH analysis in 1 of 45 cases of mantle cell lymphomas,11 but has not been reported previously in MZBCLs. Loss of 1p was seen in 1 of 25 cases of MZBCL.16
Immunocytoma
No CGH analysis of immunocytomas has been reported previously. The
gains at chromosomes 3 and 18 are common abnormalities in
MZBCLs,16
whereas losses at 11p14 and 21q21 are unusual in
non-Hodgkin lymphomas in general.8
Diffuse Large B-Cell Lymphomas
Previous CGH studies of DLBCLs have revealed chromosomal
abnormalities in more than 90% of the tumors
examined.10
25
26
Frequently, the karyotype is complex,
with five to six aberrations detected on average in each case.
In two of three of the DLBCLs, gains at 11q and losses at 6q were observed. CGH analysis of central nervous system (CNS) DLBCL has revealed gains at 11q, 16p, 18q and losses at 6q as frequent findings.26 27 In a study of DLBCLs with nodal, splenic and extranodal manifestations, Monni et al.25 observed gains at chromosomes X (41%), 1q (38%), 7 (31%), 3 (24%), and 6p, 11, 12, and 18 (21% each), and losses at 6q (38%), X (21%), 1p (14%), and 8p (10%). Gains at chromosome 8, with a minimal common region at 8q23-24.2, were observed in 33% of recurrent tumors compared with only 6% of primary tumors.25 Deletions at 6q appear to be most frequently seen in the 6q16-q21 region with a 2-Mb region at 6q21 as the minimal common region.28
Involvement of 19q13 is of interest because of the presence of the BCL3 gene at 19q13.1. Conventional cytogenetic analysis has revealed translocations at 19q13 both in Hodgkin disease and in non-Hodgkin lymphomas.29 30
Amplifications of 2p are observed in 5% to 10% of the cases,10 25 31 more frequent in recurrent than in primary tumors.25 Gains at 2p with amplification of the REL gene have been associated with extranodal presentation.31 Breaks at 3p14 are of interest, because they may disrupt the tumor suppressor gene FHIT.32 The most common abnormality is a loss of the FHIT gene, but in some non-Hodgkin lymphomas, breaks at 3p14 have been observed with subsequent gains in the distal part of 3p.16
Fragile Sites
The association of intrachromosomal breaks with fragile sites in
non-Hodgkin lymphomas has also been observed by other
investigators.11
33
Fragile sites are thought to
contribute to chromosomal instability in tumor cells and have been
associated with deletions, amplifications, and
translocations.22
Fragile sites may represent areas of
late-replicating DNA and could be destabilized as a result of increased
replication of the tumor cells. They are also targets for
mutagens.34
35
A possible mechanism for fragile sites in
the generation of amplified chromosomal units is the initiation of
breakagefusionbridge cycles.36
Breaks at fragile sites
may interrupt tumor-suppressor genes. An example is breaks at FRA3B
where the FHIT gene is located.22
32
Clinical Status
We did not detect any abnormalities that were associated
with orbital presentation of lymphomas. In a study of chromosomal
imbalances in CNS DLBCLs, Rickert et al.26
also observed
that the aberrations in CNS DLBCLs were similar to those in DLBCLs at
other locations unrelated to cerebral presentation. Some of the
abnormalities detected in our study are uncommon, however, and may
point to the location of genes that could be relevant in orbital
presentation. Because the number of tumors with chromosomal
abnormalities was low, further studies are needed to clarify this
question.
The CGH karyotype of the DLBCLs was different from that of the MZBCLs and the immunocytoma. Considerable variation in the karyotype was also observed among tumors from the same subgroup. The only abnormalities that were common to more than one tumor were gains at 3q and losses at 7q31 in two of four MZBCLs and gains at 11q and losses at 6q in two of three DLBCLs. Although such imbalances are among the most frequently observed abnormalities in larger series of these tumors,16 23 25 they are present in only half of the tumors examined. They could define a subset of MZBCLs or DCBCL, but their relevance as genetic markers in lymphoma classification remains to be determined.
Studies of gastrointestinal DLBCLs10 and mantle cell lymphoma11 indicate that patients with tumors that have a less complex molecular cytogenetic karyotype (no aberrations or one aberration) have a significantly higher probability of survival than patients having tumors with two or more aberrations. All five patients in our series in whom recurrent disease developed had primary tumors with chromosomal abnormalities. More patients and longer follow-up time are needed, however, to determine whether CGH analysis is prognostically relevant in patients with orbital lymphomas.
| Footnotes |
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Commercial relationships policy: N.
The publication costs of this article were defrayed in part by page charge payment. This article must therefore be marked "advertisement" in accordance with 18 U.S.C.
1734 solely to indicate this fact.
Corresponding author: Eyvind Rødahl, Department of Ophthalmology, Haukeland University Hospital, N-5021 Bergen, Norway; eyvind.rodahl{at}haukeland.no.
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