Analysis of Cerebrospinal Fluid Cells From an

American Child with Burkitt's Lymphoma

H O W A R D B. F U C H S , B.A., A N D R O B E R T C. ROSAN, M.D.

Cardinal Glennon Memorial Hospital for Children, St. Louis, Missouri

ABSTRACT

Fuchs, Howard B., and Rosan, Robert C : Analysis of cerebrospinal fluid

cells from an American child with Burkitt's lymphoma. Am J Clin Pathol
64: 238-240, 1975. T u m o r cells in the cerebrospinal fluid of an American
child with Burkitt's lymphoma are described. The morphology of the cells

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was demonstrated better by use of the "millipore" technic and hematoxylin
and eosin staining than by the Wright-stained smear. (Key words: Cere-
brospinal fluid cytology; Burkitt's lymphoma.)

I N THIS PAPER, we describe cells from the
cerebrospinal fluid (CSF) of an American
patient with Burkitt's lymphoma, with
emphasis on the technic of preparing the
specimen. Infiltration of the central
nervous system (CNS) is a common com-
plication of the latter stages of Burkitt's
lymphoma 8 with concomitant symptoms
such as paraplegia, cranial nerve palsies,
or elevated intracranial pressure. 7 Thus,
proper cytology of CSF is important to
determine whether the cells present are
malignant and require cancer therapy,
or benign, perhaps indicative of infectious
disease. Indeed, these patients are at
greater risk for infectious disease than
normal individuals. For example, Ziegler
and associates 8 found evidence of malig-
nant cells in CSF in only three of ten pa-
tients who had Burkitt's lymphoma with
symptoms of paraplegia. It also should be
noted that in all cases in which the tumor
cells were found in the CSF the patients
were children of East Africa.
Received December 18, 1974; accepted for pub-
lication January 10, 1975.
Address reprint requests to Howard B. Fuchs, B.A.,
New York Medical College, Basic Science Building,
Box # 3 9 3 , Valhalla, N.Y. 10595.
Previously, CSF cells from Burkitt
lymphoma cases were described by Janota, 3
who used phase-contrast micrography.
Others have described simple smears of
CSF, but Wright 7 found these yielded too
many " s m e a r cells" (unidentifiable
smudges), which he believed to be rem-
nants of Burkitt cells. He suggested the
addition of 20% serum to the CSF prior
to centrifugation, before smearing the
deposit, in order to help keep the fragile
Burkitt cells intact.
Methods
Our patient was a 7-year-old white native
American boy, in whom the diagnosis of
Burkitt's lymphoma had been established
by biopsy of an abdominal mass on April
29, 1971. He was now referred for symp-
toms of CNS disorders, etiology undeter-
mined.
From freshly obtained CSF, uncentri-
fuged, we took two separate samples. One
was stained routinely with Wright's stain
by the technician. The other smear was
prepared by filtering through a "millipore"
filter paper (0.45 (JL) and staining the disk
with ordinary hematoxylin and eosin.

238
August 1975 CSF CYTOLOGY IN BURKITT'S LYMPHOMA 239

FIG. 1. "Starry-sky" pattern in cells

from regional node of neck. Formalin
I
*"W %'
fixation. Hematoxylin and eosin.

v
w

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Results present in the cells, with conspicuously
defined nuclear membranes, and two to
T h e technician's differential count of the
five prominent nucleoli per cell; frequent
Wright-stained specimen was recorded as
mitotic figures were also present. T h e cyto-
100% lymphocytes and 0 neutrophils. In
plasm was reduced to a very thin rim
fact, unidentifiable "smear cells" were pres-
around the nuclei (Fig. 3). Consequently,
ent, but even the intact leukocytes could
what appeared to be, perhaps, atypical
only be identified at best as being an
lymphocytes in the conventional smear,
atypical part of the lymphocytic series
were almost certainly classic Burkitt malig-
(Fig. 2). In contrast, in most of the leuko-
nant cells, as described by others. 1,4>5 ' 7,8
cytes on the hematoxylin and eosin-
stained disk (>90%) many features of the Discussion
malignant Burkitt cell could be identified. Major implications of this finding are
Large, round, fairly uniform nuclei were the critical role of technic in the diagnosis

sj^R'

#
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FIG. 2 (left). Cerebrospinal fluid smear. Wright's stain, x 1,000.

FIG. 3 (right). Cerebrospinal fluid "millipore" preparation, same specimen as above; 95% ethanol
fixation. Hematoxylin and eosin. x 1,000.
240 FUCHS AND ROSAN
of CSF cells from cases of Burkitt's lym-
phoma and the possibility of error from
routine methods. We agree with Wright's
suggestion of "extra precaution" for
Burkitt's lymphoma; the technologist must
be made aware of the need for special
technic in handling these specimens.
We speculate that more attention to those
morphologic details may help resolve cer-
tain problems in the analysis of CSF speci-
mens from American patients who have
Burkitt's lymphoma. For example, ac-
cording to recent findings by Pagano and
associates, 6 American Burkitt's lymphoma
material showed an absence of viral DNA,
unlike the tumor-infiltrated tissue of
African patients with Burkitt's lymphoma,
where evidence of Epstein-Barr (EB) viral
DNA has been demonstrated. Hirshaut
and co-workers 2 found no evidence of
increased EB virus antibody prevalence
or titer in the sera of American patients
with Burkitt's lymphoma compared with
normal Americans. These findings suggest
that although the paraffin-section mor-
phologies of the "classic" malignant Burkitt
cell might be the same for both African
A.J.C.P.—Vol.64
and American types of lymphoma, the
virologies and perhaps even the etiologies
of the two might not. Perhaps an intensive
study and comparison of African and
American CSF cytology could help to
illuminate this problem. At least, more
work should be done to investigate possible
other differences.
References
1. Herlitzker AJ, Badruddoja M, Dube VE:
"Clinical and pathological differences of
* Burkitt's lymphoma. Surg Gynecol Obstet
136:81-86, 1973
2. Hirshaut Y, Cohen M, Stevens DA. Serological
differences between American and African
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Burkitt's lymphoma. Fed Proc 30:301, 1971
3. Janota I: Malignant lymphoma—cells in the
cerebrospinal fluid. Lancet 11:677-678, 1964
4. Memoranda, Histopathological definition of
Burkitt's tumor. Bull WHO 40:601-607, 1969
5. O'Conor GT, Davies NP: Malignant tumors in
African children. J Pediatr 56:526-535, 1960
6. Pagano JS, Huong CH, Levine P: "Absence of EB
viral DNA in American Burkitt's lymphoma.
N Engl J Med 289:1395-1399, 1973
7. Wright DH: "Burkitt's lymphoma: A review of the
pathology, immunology, and possible
etiologic factors. Pathol Annu 6:337-363,
1971
8. Ziegler JL, Bluming AZ, Morrow RH, et al:
Central nervous system involvement in
Burkitt's lymphoma. Blood 36:718-727, 1970