Pathology Commons^™

Androgen Receptor Signaling In Prostate Cancer And Therapeutic Strategies, Aasems Jacob, Rishi Raj, Derek B. Allison, Zin W. Myint

Markey Cancer Center Faculty Publications

Understanding of the molecular mechanisms of prostate cancer has led to development of therapeutic strategies targeting androgen receptor (AR). These androgen-receptor signaling inhibitors (ARSI) include androgen synthesis inhibitor-abiraterone and androgen receptor antagonists-enzalutamide, apalutamide, and darolutamide. Although these medications provide significant improvement in survival among men with prostate cancer, drug resistance develops in nearly all patients with time. This could be through androgen-dependent or androgen-independent mechanisms. Even weaker signals and non-canonical steroid ligands can activate AR in the presence of truncated AR-splice variants, AR overexpression, or activating mutations in AR. AR splice variant, AR-V7 is the most studied among these and …

A Case Report Of Metastatic Castration-Resistant Prostate Cancer Harboring A Pten Loss, Zin W. Myint, Derek B. Allison, Carleton S. Ellis

Internal Medicine Faculty Publications

The treatment landscape of metastatic castration-resistant prostate cancer (mCRPC) has dramatically improved over the last decade; however, patients with visceral metastases are still faced with poor outcomes. Phosphatase and tensin homolog (PTEN) loss is observed in 40%–60% of mCRPC patients and is also associated with a poor prognosis. Several PI3K/AKT/mTOR pathway inhibitors have been studied, with disappointing anti-tumor activity. Here, we present a case of a patient with heavily treated mCRPC who had a modest tumor response to concurrent carboplatin, abiraterone acetate/prednisone, and liver-directed radiation therapy. We discuss the potential rationale supporting the use of this combination therapy …

Rapid 3d Reconstruction Guided Embolization For Catastrophic Bleeding Following Vacuum Assisted Breast Biopsy; A Case Report And Review Of The Literature, Martin Halicek, Chenghao Qian, Driss Raissi, Xiaoqin Wang, Yevgen Chornenkyy, William B. Bates, Michael Winkler

Radiology Faculty Publications

The most clinically significant complication associated with stereotactic core needle biopsy of the breast is hematoma formation, which only occurs in less than 1% of biopsies and may require treatment. Cases of uncontrollable bleeding, refractory to repeated compression, resulting from biopsy are exceedingly rare. We present a case of catastrophic, uncontrollable bleeding and large hematoma formation resulting from stereotactic vacuum-assisted breast biopsy of a breast mass identified in screening mammography. Percutaneous embolization was planned and guided using 3D reconstructions from computed tomographic angiography, and bleeding was successfully controlled with micro-coil embolization.

Innate Immune Activation By Checkpoint Inhibition In Human Patient-Derived Lung Cancer Tissues, Teresa W. M. Fan, Richard M. Higashi, Huan Song, Saeed Daneshmandi, Angela L. Mahan, Matthew S. Purdom, Therese J. Bocklage, Thomas A. Pittman, Daheng He, Chi Wang, Andrew N. Lane

Center for Environmental and Systems Biochemistry Faculty Publications

Although Pembrolizumab-based immunotherapy has significantly improved lung cancer patient survival, many patients show variable efficacy and resistance development. A better understanding of the drug’s action is needed to improve patient outcomes. Functional heterogeneity of the tumor microenvironment (TME) is crucial to modulating drug resistance; understanding of individual patients’ TME that impacts drug response is hampered by lack of appropriate models. Lung organotypic tissue slice cultures (OTC) with patients’ native TME procured from primary and brain-metastasized (BM) non-small cell lung cancer (NSCLC) patients were treated with Pembrolizumab and/or beta-glucan (WGP, an innate immune activator). Metabolic tracing with ¹³C₆-Glc/ …

Discrepancy Between Pcr Based Sars-Cov-2 Tests Suggests The Need To Re-Evaluate Diagnostic Assays, Zain Mushtaq, Sadia Shakoor, Akber Kanji, Najma Shaheen, Asghar Nasir, Zeeshan Ansar Ahmed, Imran Ahmed, Syed Faisal Mahmood, Rumina Hasan, Zahra Hasan

Section of Internal Medicine

Objective: We investigated the discrepancy between clinical and PCR-based diagnosis of COVID-19. We compared results of ten patients with mild to severe COVID-19. Respiratory samples from all cases were tested on the Roche SARS-CoV-2 (Cobas) assay, Filmarray RP2.1 (bioMereiux) and TaqPath™ COVID19 (Thermofisher) PCR assays.
Results: Laboratory records of ten patients with mild to severe COVID-19 were examined. Initially, respiratory samples from the patients were tested as negative on the SARS-CoV-2 Roche® assay. Further investigation using the BIOFIRE® Filmarray RP2.1 assay identified SARS-CoV-2 as the pathogen in all ten cases. To investigate possible discrepancies between PCR assays, additional testing was …

A Prospective Observational Study Of Community Acquired Pneumonia In Kenya: The Role Of Viral Pathogens, Jamila Nambafu, Mary Achakolong, Fridah Mwendwa, Jumaa Bwika, Felix Riunga, Samuel Gitau, Hanika Patel, Rodney Adam

Internal Medicine, East Africa

Background: Lower respiratory tract infections continue to contribute significantly to morbidity and mortality across all age groups globally. In sub-Saharan Africa, many studies of community acquired pneumonia in adults have focused on HIV-infected patients and little attention has been given to risk factors and etiologic agents in an urban area with a more moderate HIV prevalence.

Methods: We prospectively enrolled 77 patients admitted to a 280 bed teaching hospital in Kenya with radiographically confirmed community acquired pneumonia from May 2019 to March 2020. The patients were followed for etiology and clinical outcomes. Viral PCR testing was performed using …

Evaluation Of Glutaminase Expression In Prostate Adenocarcinoma And Correlation With Clinicopathologic Parameters, Zin W. Myint, Ramon C. Sun, Patrick J. Hensley, Andrew C. James, Peng Wang, Stephen E. Strup, Robert J. Mcdonald, Donglin Yan, William H. St. Clair, Derek B. Allison

Internal Medicine Faculty Publications

High Glutaminase (GLS1) expression may have prognostic implications in colorectal and breast cancers; however, high quality data for expression in prostate cancer (PCa) are lacking. The purpose of this study is to investigate the status of GLS1 expression in PCa and correlated expression levels with clinicopathologic parameters. This study was conducted in two phases: an exploratory cohort analyzing RNA-Seq data for GLS1 from The Cancer Genome Atlas (TCGA) data portal (246 PCa samples) and a GLS1 immunohistochemical protein expression cohort utilizing a tissue microarray (TMA) (154 PCa samples; 41 benign samples) for correlation with clinicopathologic parameters. In the TCGA cohort, …

Association Between Obesity And Histological Tumor Budding In Patients With Nonmetastatic Colon Cancer, Tong Gan, Kurt B. Schaberg, Daheng He, Akila Mansour, Harit Kapoor, Chi Wang, B. Mark Evers, Therese J. Bocklage

Surgery Faculty Publications

Importance: Obesity is associated with increased risk of colorectal cancer (CRC) and a more aggressive disease course. Tumor budding (TB) is an important prognostic factor for CRC, but its association with obesity is unknown.

Objective: To evaluate the association of TB with obesity and other prognostic factors in colon cancer.

Design, Setting, and Participants: This cohort study involved a histological review of colon cancer specimens obtained during 7 years (January 2008 to December 2015) at the University of Kentucky Medical Center; data analysis was conducted from February 2020 to January 2021. Specimens came from 200 patients with stage I to …

Pvn Activity In Cardiac Sympathetic Afferent Reflex (Csar) Control And Cardiovascular Function, Shane H. Boomer

Honors Thesis

Regulation of blood pressure is essential in bodily health. Hypertension and hypotension can be associated with varying diseases that could potentiate further disease. From this, understanding the mechanisms that regulate blood pressure is important within medicine. In my study, I will be focusing on a cardiovascular reflex that is less well understood, the cardiac sympathetic afferent reflex (CSAR). In particular, this work will examine sex differences in this reflex in overall function and in the involvement of an area of the brain called the paraventricular nucleus (PVN). We will test the hypothesis that there will be a significant difference between …

Novel Fusion Ktn1-Prkd1 In Cribriform Adenocarcinoma Of Salivary Glands Located In The Parotid Gland: Case Report Including Cytologic Findings, Treeva K. Jassim, T. Sheng, Shulin Zhang, Sainan Wei, Susanne M. Arnold, Alexandra E. Kejner, Therese J. Bocklage, Julie C. Dueber

Pathology and Laboratory Medicine Faculty Publications

Background
Cribriform adenocarcinoma of salivary glands (CASG) is a rare, predominantly minor salivary gland tumor first described in 1999. Because the tumor shares morphologic and molecular features with polymorphous adenocarcinoma (PAC), in 2017, the World Health Organization (WHO) included CASG within the spectrum of PAC. Almost 75% of CASG harbor molecular alterations in the PRKD (Protein kinase D) gene family, and some cases show ARID1A (AT-rich interaction domain 1A)-PRKD1 or DDX3X (DEAD-Box Helicase 3 X-Linked)-PRKD1 fusions.

Case presentation
A 39-year-old man presented with headache and painless right cheek mass of two years duration. Imaging showed a well-circumscribed, …

The Association Of Chest Radiographic Findings And Severity Scoring With Clinical Outcomes In Patients With Covid-19 Presenting To The Emergency Department Of A Tertiary Care Hospital In Pakistan, Raima Kaleemi, Kiran Hilal, Ainan Arshad, Russell S. Martins, Avinash Nankani, Tanveer Ul Haq, Sundas Basharat, Zeeshan Ansar

Department of Radiology

Introduction: While chest x-rays (CXRs) represent a cost-effective imaging modality for developing countries like Pakistan, their utility for the prognostication of COVID-19 has been minimally explored. Thus, we describe the frequency and distribution of CXR findings, and their association with clinical outcomes of patients with COVID-19.
Methods: All adult (≥ 18 years) patients presenting between 28th February-31st May to the emergency department of a tertiary care hospital in Pakistan, who were COVID-19 positive on RT-PCR with CXR done on presentation, were included. A CXR Severity Score (CXR-SS) of 0-8 was used to quantify the extent of pulmonary infection on CXR, …

Pregabalin-Induced Myopathy In A Double Lung Transplant Recipient, Vishwajit Hegde, Nidhi Shekar, Filip G. Garrett, Maher A. Baz, Michael I. Anstead

Internal Medicine Faculty Publications

Pregabalin is a gamma-aminobutyric acid (GABA) derivative that was commercially approved by the Food and Drug Administration (FDA) in 2004. It is commonly used in the treatment of diabetic neuropathy, peripheral neuropathy, and spinal cord injury. We present the case of a 36-year-old Caucasian male double lung transplant recipient who presented with an 18-month history of fatigue and muscle weakness. He had elevated creatinine kinase level and his muscle biopsy showed evidence of drug-induced myopathy that improved after the cessation of pregabalin. We present a case of drug-induced myopathy as a rare complication of pregabalin therapy in a double lung …

Combating Acquired Resistance To Mapk Inhibitors In Melanoma By Targeting Abl1/2-Mediated Reactivation Of Mek/Erk/Myc Signaling, Rakshamani Tripathi, Zulong Liu, Aditi Jain, Anastasia Lyon, Christina Meeks, Dana Richards, Jinpeng Liu, Daheng He, Chi Wang, Marika Nespi, Andrey Rymar, Peng Wang, Melissa Wilson, Rina Plattner

Pharmacology and Nutritional Sciences Faculty Publications

Metastatic melanoma remains an incurable disease for many patients due to the limited success of targeted and immunotherapies. BRAF and MEK inhibitors reduce metastatic burden for patients with melanomas harboring BRAF mutations; however, most eventually relapse due to acquired resistance. Here, we demonstrate that ABL1/2 kinase activities and/or expression are potentiated in cell lines and patient samples following resistance, and ABL1/2 drive BRAF and BRAF/MEK inhibitor resistance by inducing reactivation of MEK/ERK/MYC signaling. Silencing/inhibiting ABL1/2 blocks pathway reactivation, and resensitizes resistant cells to BRAF/MEK inhibitors, whereas expression of constitutively active ABL1/2 is sufficient to promote resistance. Significantly, nilotinib (2nd generation …

Development, Expansion And Role Of Myeloid-Derived Suppressor Cells In Post-Sepsis Immune Suppression, Tuqa Alkhateeb

Electronic Theses and Dissertations

Myeloid-derived suppressor cells (MDSCs) numbers increase significantly in sepsis and are associated with high mortality rates. These myeloid cell precursors promote immunosuppression, especially in the late (post sepsis) stage. However, the mechanisms that underlie MDSC expansion and programming are not completely understood. To investigate these mechanisms, we used a cecal-ligation and puncture (CLP) mouse model of polymicrobial sepsis that progresses from an early/acute proinflammatory phase to a late/chronic immunosuppressive phase. Previous studies in our laboratory showed that microRNA (miR)-21 and miR-181b elevate levels of the transcription factor nuclear factor 1 (NFI-A) that promotes MDSC expansion. We report here that miR-21 …

Invasive Pulmonary Infection By Syncephalastrum Species: Two Case Reports And Review Of Literature, Memoona Irshad, Nosheen Nasir, Urooj Haider Hashmi, Joveria Farooqi, Syed Faisal Mahmood

Section of Internal Medicine

Background: Syncephalastrum species belong to the class Zygomycetes and order Mucorale. These are found in the environment and tropical soil, usually presenting as colonizers and rarely cause human infection. Syncephalastrum racemosum is a species of the genus Syncephalastrum and is the most commonly identified pathogen. Most cases are reported in immunocompromised individuals, such as patients on long term steroids, poorly controlled diabetes, or patients with malignancy.
Case presentation: We are describing two cases of rare fungal infection by Syncephalastrum species causing invasive pulmonary manifestation. Both patients had compromised immune status and presented with worsening dyspnea to the emergency room. Both …

A Case Series Of Hyponatremia And Management In Hospitalized Patients, Jake N. Cho, Rebecca Ong, Izuchukwu Nwakoby

Nephrology

No abstract provided.

Point-Of-Care Hpv Molecular Diagnostics For A Test-And-Treat Model In High-Risk Hiv Populations, Shahin Sayed, Michael Chung, Marleen Temmerman

Pathology, East Africa

Strategies for cervical cancer prevention and control in low-income and middle-income countries (LMICs) require concerted efforts to improve screening and access to treatment, especially in high-risk HIV populations. LMICs bear the largest burden of HIV infection, human papillomavirus (HPV) infection is common among HIV-infected women, risk of cervical cancer is increased in women with HIV/AIDS, and HIV clinics provide opportunities to screen and treat for cervical cancer in this population.

Don’T Be Blind To The Diagnosis: An Intriguing Case Of Monocular Blindness, Kourtney Erickson Do, Kaitlyn L. Buzard Do, Daniel Tseytlin Do, Carolyn Casey Do, Eugene Alexandrin Md

Department of Medicine

No abstract provided.

The Society Of Abdominal Radiology At 10 Years: Reflections, Status Report, And Look To The Future, Manju Ambelil, David M Saulino, Atilla Ertan, Andrew W Dupont, Mamoun Younes

Faculty, Staff and Student Publications

CONTEXT.—: Recent studies examining immunohistochemical staining of colorectal biopsies for cytomegalovirus (CMV) reported that some cases showed only occasional small positive nuclei that were called equivocal for CMV.

OBJECTIVES.—: To determine the extent and clinical significance of equivocal CMV staining in colorectal biopsies.

DESIGN.—: Two-hundred twenty-one consecutive cases of colon and rectal biopsies that were stained for CMV by immunohistochemistry were retrieved from our files and reviewed. Staining results were recorded as negative, unequivocal, or equivocal. Results were correlated with clinicopathologic data, results of polymerase chain reaction studies for CMV, and treatment history.

RESULTS.—: Fifty-two cases (24% of all tested, …

Metastatic Breast Cancer In Kenya: Presentation, Pathologic Characteristics, And Patterns-Findings From A Tertiary Cancer Center, Etoroabasi Ekpe, Asim Jamal, Jasmit Shah, Judith S. Jacobson, Shahin Sayed

Internal Medicine, East Africa

Purpose: The purpose of this research was to describe the sociodemographic and clinical characteristics of Kenyan women with metastatic breast cancer diagnosed and treated at Aga Khan University Hospital in Nairobi, Kenya from 2012 to 2018.

Patients and Methods: We reviewed charts of Kenyan women with metastatic breast cancer and analyzed sociodemographic data, breast cancer risk factors, and tumor characteristics associated with stage at diagnosis, receptor status (ie, estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 [HER2]), and site of metastasis using χ2, analysis of variance, two-sample t tests, and logistic regressions.

Results: A total of 125 …

Acinetobacter Infections: A Retrospective Study To Determine In Hospital Mortality Rate And Clinical Factors Associated With Mortality, Rajiv Patel, Jasmit Shah, Gunturu Revathi, Wangari Siika, Reena Shah

Internal Medicine, East Africa

A retrospective case series of acinetobacter infections at a tertiary hospital in Nairobi was conducted to determine the mortality rate and factors associated with mortality. Over an eight-year period, 80 clinically significant infections were identified. The majority of infections were ventilator-associated pneumonia (40%) and bloodstream infections (30%). Eighty-six percent of the isolates were multi-drug resistant. The mortality rate in the study cohort was 45%. Twelve patients grew Acinetobacter spp. within 48 h of hospitalization, and three of these patients had no prior healthcare contact. The mean Sequential Organ Failure Assessment score was associated with mortality from acinetobacter infections.

Tumor Heterogeneity As A Predictor Of Response To Neoadjuvant Chemotherapy In Locally Advanced Rectal Cancer, Alissa Greenbaum, David R. Martin, Therese J. Bocklage, Ji-Hyun Lee, Scott A. Ness, Ashwani Rajput

Pathology and Laboratory Medicine Faculty Publications

BACKGROUND: Neoadjuvant chemoradiotherapy (nCRT) is the standard of care for locally advanced adenocarcinoma of the rectum, but it is currently unknown which patients have disease that will respond. This study tested the correlation between response to nCRT and intratumoral heterogeneity using next-generation sequencing assays.

PATIENTS AND METHODS: DNA was extracted from formalin-fixed, paraffin-embedded biopsy samples from a cohort of patients with locally advanced rectal adenocarcinoma (T3/4 or N1/2 disease) who received nCRT. High read-depth sequencing of > 400 cancer-relevant genes was performed. Tumor mutations and variant allele frequencies were used to calculate mutant-allele tumor heterogeneity (MATH) scores as measures of intratumoral …

Initial Management Of Meningiomas: Analysis Of The National Cancer Database, Catherine R. Garcia, Stacey A. Slone, Monica Chau, Janna H. Neltner, Thomas A. Pittman, John L. Villano

Neurology Faculty Publications

BACKGROUND: Meningiomas are the most common central nervous system tumor. We describe current trends in treatment and survival using the largest cancer dataset in the United States.

METHODS: We analyzed the National Cancer Database from 2004 to 2014, for all patients with diagnosis of meningioma.

RESULTS: 201,765 cases were analyzed. Patients were most commonly White (81.9%) females (73.2%) with a median age of 64 years. Fifty percent of patients were diagnosed by imaging. Patients were reported as grade I (24.9%), grade II (5.0%), grade III (0.7%), or unknown WHO grade (69.4%). Patients diagnosed by imaging were older, received treatment in …

Evaluation Of Quality Of Warfarin Therapy By Assessing Patient's Time In Therapeutic Range At A Tertiary Care Hospital In Pakistan, Haris Hakeem, Ammar Zaman Khan, Kashif Aziz, Ayesha Abbasi, Anam Haider, Bushra Moiz, Mohammad Wasay

Section of Neurology

Objective: To assess the time in therapeutic range in patients on warfarin anti-coagulation therapy.

Methods: The retrospective chart review was conducted at Aga Khan University Hospital, Karachi, and comprised data of patients having undergone anti-coagulation with warfarin from January 2013 to April 2015. To determine the mean time in therapeutic range, Rosendaal method was used. Association of time in therapeutic range with the composite outcome, bleeding and thromboembolic events was also assessed. Percentage of patients with time in therapeutic range <60% was calculated.

Results: There were 92 patients whose median time in therapeutic range was 34.9% (interquartile range: 20.0- 55.7). Overall, 71(77.2%) …

Infection Of A Ventricular Septal Defect Patch With Acremonium Species, Nosheen Nasir, Kauser Jabeen, Joveria Farooqi, Binish Arif Sultan, Afia Zafar, Aamir Hameed Khan, Muneer Amanullah, Farheen Ali

Section of Internal Medicine

A ventricular septal defect (VSD) patch infection with Acremonium species isolated from vegetation and blood culture is described. Antifungal treatment was discontinued after 3 months and patient developed relapse. Surgery with prolonged oral voriconazole was instituted with recovery. We emphasize importance of surgery and prolonged therapy to treat such infections.

Mammographic Breast Density And Breast Cancer Molecular Subtypes: The Kenyan-African Aspect, Asim Jamal, Maeve Mullooly, Shahin Sayed, Rose Ndumia, Innocent Abayo, James Orwa, Ronald Wasike, Zahir Moloo, Gretchen L. Gierach

Internal Medicine, East Africa

Introduction: Data examiningmammographic breast density (MBD) among patients in Sub-Saharan Africa are sparse.We evaluated how MBD relates to breast cancer characteristics in Kenyan women undergoing diagnostic mammography.

Methods: This crosssectional study included women with pathologically confirmed breast cancers (𝑛 = 123). Pretreatment mammograms of the unaffectedbreast were assessed to estimate absolute dense area (cm2), nondense area (cm2), and percent density (PD). Relationships between density measurements and clinical characteristics were evaluated using analysis of covariance.

Results: Median PD and dense area were 24.9% and 85.3 cm2. Higher PD and dense area were observed in younger women (𝑃 < 0.01). Higher dense and nondense areas were observed in obese women (𝑃-trend < 0.01). Estrogen receptor (ER) positive patients (73%) had higher PD and dense area than ER-negative patients (𝑃 ≤ 0.02). Triple negative breast cancer (TNBC) patients (17%) had lower PD and dense area (𝑃 ≤ 0.01) compared with non-TNBCs. No associations were observed between MBD and tumor size and grade.

Conclusions: Our findings show …

Prevalence Of Hla-B*5701 In A Kenyan Population With Hiv Infection, Reena Shah, H. Nabiswa, Nancy Okinda, Gunturu Revathi, Mark Hawken, Nelson M.

Internal Medicine, East Africa

We read with interest the article published in your Journal entitled “Real-world persistence with antiretroviral therapy for HIV in the United Kingdom: a multicentre retrospective cohort study”1 which concluded that treatment discontinuation attributable to toxicity profile is not an uncommon event. They also acknowledged lack of data collection on HLA-B*5701 status, which would heavily influence initial ART regimen and the choice to discontinue medication. Of the 25.6 million living with Human Immunodeficiency Virus (HIV) in Africa, an estimated 1.6 million people live in Kenya.2 With an HIV prevalence of 5.6%, Kenya has upscaled HIV treatment and care in the past …

Gastrointestinal Involvement Of Testicular Germ Cell Tumor: A Case Report And Literature Review., Oluwaseun Shogbesan, Abdullateef Abdulkareem, Asad Jehangir, Sunila Byreddy, Sharon Swierczynski, Anthony A. Donato

Reading Hospital Internal Medicine Residency

Testicular germ cell tumors (GCT) are the commonest solid tumors in young men. Typical presentation is with painless scrotal swelling; however, symptoms related to complications or metastasis may be the initial presentation. Gastrointestinal (GI) metastasis is seen in about 5% of patients with germ cell tumors and presentation is commonly with GI bleed. It is important to have GCT as a differential diagnosis of GI bleed in young men presenting with unexplained anemia as direct questioning about scrotal swelling and genital examination when appropriate will guide further investigation and facilitate prompt diagnosis. We present a case of a 26-year-old man …

Dome-Type Carcinoma Of The Ascending Colon: A Case Report, Patrick Hickey Do, Shanth A. Goonewardene Md, Shashin Shah Md, Hiral N. Shah Md, Anthony G. Auteri Md

Department of Medicine

No abstract provided.

Primary Extranodal Marginal Zone Lymphoma Of The Endometrium: Report Of Four Cases And Review Of Literature, F. C. Tahmasebi, S. Roy, J. E. Kolitz, F. Sen, J. Laser, X. Zhang

Journal Articles

Primary extranodal marginal zone lymphoma of the endometrium (PEMZL-EM) is exceedingly rare and has not been well characterized. Herein, we study the clinicopathological, cytogenetic and molecular features of four cases, the largest case series reported to date. The median age of the four patients was 59 years. Clinical presentations included abnormal vaginal bleeding (three cases) and incidental finding (one case). There were no constitutional symptoms in any of the cases. None of the patients had evidence of lymphoma in any other anatomic sites including bone marrow. Histologically, the lymphoma was characterized by a nodular proliferation of small lymphocytes admixed with …