Sternberg-Reed Cells inthePeripheral Blood ofPatients with

Sternberg-Reed Cells in the Peripheral Blood

of Patients with Hodgkin’s Disease

By BaavriiA A. BOURONCLE

With the technical assistance of Rosemary Mann

I T IS well known that Hodgkin’s disease can originate in lymph nodes,spleen, liver and other organs of the reticuloendothelial system. From there

it spreads throughout the body by local invasion, by lymphatic dissemination,

and by hematogenous dissemination.

The possibility of the hematogenous dissemination of Hodgkin’s disease was

first suggested by Dorothy Reed’ in her classic description of the morbid

pathology of Hodgkin’s disease in 1902: “These giant cells occur in great

numbers in the large lymph sinuses of the gland and occasionally occur in

blood vessels.” In 1926, Jeanselme and Marchal2 reported Sternberg-Reed cell

emboli observed within blood vessels in biopsied and postmortem organs of a

patient who had died from Hodgkin’s disease. In addition, these giant cells

were described as being frequent in perivascular locations and in some sections

appeared to be passing through a vessel into the parenchyma.

These early observations support the possibility of hematogenous dissemina-

tion of Hodgkin’s disease. However, the presence of Sternberg-Reed cells in

routine peripheral blood smears is a rare occurrence and only 8 isolated cases

have been reported in the world’s literature.31#{176} Among 890 patients studied

in our institution, Sternberg-Reed cells were found in the routine peripheral

blood examinations in only 2 patients with advanced generalized disease.

In this report, we present the results of our search for Sternberg-Reed cells

in the smears of leukocyte concentrates in 135 patients with confirmed diag-

noses of Hodgkin’s disease. We also report our comparative observations of

leukocyte concentrates in the splenic vein and splenic artery of 3 splenecto-

mized patients who had Hodgkin’s disease.

MATERIALS AND METHODS

Method of Study

Among the numeroims miiethods described for the demonstration of cancer cells in the

circulating blood, we chose a simple. but not quantitative, method which is a modification of

the silicone flotation technique of Seal.” This method takes advantage of the differences in

the specific gravity of the various cells.

Dow-Corning Silicone 555 an(l 710 are blended to achieve 5 ml. of solution of a specific

gravity 1.075. Five ml. of fresh heparinized blood is carefully layered above the silicone

From the Department of Medicine, Ohio State University, Columbus, Ohio.

This investigation was supported by Public Health Service Research Grants CA-06196-

OJA1 and CA-06196-02 from the National Cancer Institute.

First submitted June 2, 1965; accepted for publication Aug. 2, 1965.

BERTHA A. BOURONCLE, M.D.: Associate Professor, Department of Medicine, Ohio State

University, Columbus, Ohio.

544

BLOOD, VOL. 27, No. 4 (APRIL), 1966

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STERNBERG-R.EED CELLS 545

solution and the tube centrifuged at 1500 rpm for 15 minutes. The Stemberg-Reed cells,

being lighter than 1.075, conic to lie on the surface of the silicone and form a distinct buffycoat which is easily aspirated with a fine Pasteur pipette. Smears are prepared, giving

special care to achieving readily visible edges and are stained with Wright’s stain. Scanning

of 10 slides for each blood sample is carried out by an expert technician. Suspicious cells are

marked on the slide with a mnicrolocator and are then personally examined and photo-

graphed by the author.

Several tests were first employed to determine the effectiveness of the above technic: (1)

Ascites tumor cells were obtained from the abdominal cavity of an infected mouse and

“seeded” in normal human blood. This saniple was processed following our technic. The

ascites tumor cells were present in stained smears in proportionate numbers to the “seeded”

cells. ( 2 ) Areas grossi� involved with Hodgkin’s disease from fresh lymiiph nodes, obtained at

stmrgerv. were scra1)ed and mixed with compatible blood from normal individtmals and then

samples were processed following the described silicone technic. Sternberg-Reed cells were

found in the stained smears proportionally to the amount of the scraped material of the

Hodgkin’s lymph node mixed with the normal blood. From the results of the above 2

experiments. we concluded that our technic is effective in isolating Sternberg-Reed or similar

cells.

Material

Employing the described silicone technic we have examined, for the past 4 years, the

peripheral blood of 135 patients who had confirmed pathologic diagnoses of Hodgkin’s

disease. During this 4-year period of observation, from 1 to 49 determinations were done on

individimal patients during the course of their illness. The total number of determinations

performed was 1060. Seventy-eight patients were males and 57 were females. The age

range was from 8 to 91 years. A group of 50 healthy individuals were used as normal

controls. Another control group consisted of 22 patients with proved diagnoses of lvmpho-

sarcoma.

In each of 3 patients with Hodgkin’s disease who underwent splenectomy for secondary

hypersplenism, 3 samples were obtained at the timime of surgery. The first sample was

obtained from the splenic artery, the second sample from the splenic vein, and the third

sample from the splenic vein after manual squeezing of the spleen by the surgeon. A total of

15 ml. of blood was obtained per sample and was divided into 3 tubes. Ten slides were

made from each tube and reviewed for the presence of Sternberg-Reed cells. A similar

experiment was carried out in three splenectomized control patients; in 1 the diagnosis was

hereditary spherocytosis, and in the other 2 it was idiopathic thrombocytopenia purpura.

RESULTS

Peripheral Blood Studies

The results of our study have demonstrated that in leukocyte concentrate

slides from patients with Hodgkin’s disease a marked increase in monocytes is

present. Many of them are large and young forms, and some have vacuoles.

Such increase in monocytes is more pronounced during the periods of activity

or in the advanced stages of their disease. This finding confirms our observa-

tions in routine peripheral white blood cell differential counts from patients

with Hodgkin’s disease.

In addition to the usual normal cells seen on the routine differential slides,

other cells were found, which are rarely or never found in routine blood

smears. We have arbitrarily classified these cells in 3 groups:

1. Atypical celLs which are rarely found in routine slides but are found in

low number in leukocyte concentrates of normal subjects.




546 I3ERTIJA A. BOURONCLE

2. Abnormal cells which are not found in either routine slides or leukocyte

concentrates of normal subjects.

3. Neoplastic cells of the Sternberg-Reed type which are only found in

patients with Hodgkin’s disease.

Among the atypical cells we found:

a. Atypical mononuclear cells which stand out because of their dark blue,

strongly basophilic cytoplasm. They frequently have a clear perinuclear area

near the nucleus. The chromatin structure of the nucleus can be either coarse

or delicate. Nucleoli are usually distinguished. They most likely represent

altered monocytes. We have found these cells in the slides prepared from

normal subjects hut in greater numbers in patients with Hodgkin’s disease

(Fig. 1).

h. Cells in niitosis ��‘ere very rarely observed in the leukocyte concentrate

slides of our normal control subjects, but they were more frequently found in

patients with Hodgkin’s disease. These mitotic cells were at different stages of

mitosis, and they seem to belong to the atypical mononuclear cells ( Fig. 2).

c. Small hinucleated cells were also found occasionally in the normal huffy

coat; they were numerous and very frequently found in the huffy coat from

Patients with Hodgkin’s disease ( Fig. 3).d. Nuclei of nlegakaryocytes of different sizes and shapes were found fre-

(lilently in the leukocytes concentrates of normal subjects, sometimes sur-rounded by normal platelets. However, intact megakaryocytes were rare. On

the contrary, in patients with Hodgkin’s disease, numerous intact megakaryo-

cytes were found, in some patients as many as 2 or 3 per oil immersion field

( Fig. 4 ). The high incidence of megakaryocytes in leukocyte concentrates has

been reported recently in patients with carcinoma.’�

C . Hi.stiocytes, also described as macrophages or reticnlimm cells, were found

in very small numbers in the leukocyte concentrates of some of the normal

subjects, being found more frequently in patients with Hodgkin’s disease. They

appeared as large cells with abundant cytoplasm, which is pale gray-blue with

a delicate edge, so that the cell membrane is difficult to discern, giving the

appearance of a veil. The cytoplasm contained vacuoles of various sizes, gran-

tiles, cellular debris, phagocytosed red cells, white cells or platelets. The nucle-

us is oval, kidney shaped or round. The nuclear strimcture has a honey-comb

appearance and stains to a light purple color (Fig. 5).

f. Endothelial celLi, often arranged in small clusters surrounded by a large

field of cytoplasm of grayish-blue color, were seldom found in leukocyte con-

centrates of normal subjects; however, they were seen in patients with Hodg-

kin’s disease.

We found that patients with Hodgkin’s disease present other abnormal cells

which are not present in either routine slides or leukocyte concentrates of

normal subjects. They include:

a. Large atypical mononuclear cells are 2 to 4 times larger than a normal

monocyte having large nuclei, with irregular structure and one or several

nucleoli and hasophilic cytoplasm (Fig. 6).




srEnNBEI�(;-1�EED CELLS 547

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*.‘ ‘iiPlate 1.-Leukocyte concentrates of peripheral blood of patients with Hodgkin’s

disease. Fig. 1: Atypical miiononuclear cell. Fig. 2: Cell in mitosis (mnetaphase)

probably ami atypical miiomionuclear cell. Fig. .3: Small binucleated cell. Fig. 4: Intact

mnegakam’�ocvte. Fig. .5: Histiocvte. Fig. 6: Large atypical rnommonimclear cell. Fig.

�: Large atypical mononuclear cell with minineroims cvtoplasmnic �‘acimoles. Fig. 8:

Large atypical binucleated cell. Reduced 20 P�’ cent from mnagmiificatiom� 2400 x




548 BERTHA A. BOURONCLE

1). Large atypical nicnonuclear celLs with numerous vacitoles ( Fig. 7).

c. Large atypical binucleated cells, some of which are elongated with the

same cytoplasmic and nuclear characteristics of the cells described above ( Fig.

8).

These three groups of abnormal cells resemble pathologically altered retic-

ulu.m cells, and morphologically we can recognize the characteristics of the

transitional stages of reticulum cells.

The next group consisted of definitely neoplastic cells and was found only in

the leukocyte concentrates of patients with Hodgkin’s disease. They are differ-

ent morphologic variations of typical Sternberg-Reed cells. Some of them are

as large as 50 microns in diameter. They are mono, binucleate or multinu-

cleated. The nucleus is large, sometimes showing lobulations; the nuclear

chromatin is of variable thickness and staining. The nucleoli are very large,

irregular in shape, and usually deeply stained ( Figs. 9-16).

Among the 135 patients with Hodgkin’s disease s’�died, 85 (63 per cent)

had negative leukocyte concentrates for abnormal cells or Sternherg-Reed

cells. Fifty (37 per cent) were positive. Of this latter group, 25 patients (18.5

per cent ) of the total number of patients studied showed the presence of

typical Sternberg-Reed cells sometime during the course of their illness.

The abnormal cells described were found mainly during the time of activity

of Hodgkin’s disease, but occasionally large atypical hinucleate and large

atypical mononuclear cells were found during the time of clinical remission.

Stemberg-Reed cells were found only in patients showing generalized and

advanced stages of their Hodgkin’s disease. In 18 patients, these cells were

found from 4 months to 1 day prior to death. However, 4 patients in whom

Sternberg-Reed cells were found in the peripheral blood still responded to

therapy and obtained further remissions of 1#{189}to 3 years duration. Three

patients who had Stemberg-Reed cells in their leukocyte concentrates are still

alive and responding to therapy.

We have also observed that the presence of Stemberg-Reed cells has l)cen

more frequently associated with the involvement of abdominal organs by

Hodgkin’s disease.

Splenic Studies

Of interest are the results of our observations in leukocyte concentrates from

samples obtained at the time of splenectomy on 3 patients with Hodgkin’s

disease. Patient 1 was in an advanced stage of Hodgkin’s disease at the time of

surgery, and patients 2 and 3 developed secondary hemolytic anemia while

they were in earlier stages of their disease.

Patient 1 illustrates the results of our splenic studies. We found that after

careful scanning of 10 slides prepared from each of 3 samples, no Sternberg-

Reed cells were found in the first blood sample obtained from the splenic

artery, and only 1 large atypical binucleate cell was seen. In the second

sample, obtained from the splenic vein, 12 abnormal cells and 5 Stemberg-

Reed cells were found. In the third sample, obtained from the splenic vein




15

#{149}1

STERNBERC-REED CELLS 549

Plate 2.-Leukocyte concentrates of peripheral blood of patients with Hodgkin’sdisease. Sternberg-Reed cells: Fig. 9: Bimiucleated and elomigated. Fig. 10: Binu-cleated with prominent nucleoli. Fig. 11: Binucleated with nucleoli. Fig. 12: Bi-

nucleated, lobulated with c�toplasmic vacuoles. Fig. 1.3: Two cells in the same field.

Fig. 14: Trinucleated. Fig. 15: Binucleated with lobulated nuclei and vacuoles.

Fig. 16: Multinucleated with prominent nucleoli and with vacuoles. Reduced 20

per cent from magnification 2400 x.




550 BERThA A. BOURONCLE

after manual squeezing of the spleen by the surgeon, 21 abnormal cells and 12

Stemberg-Reed cells were detected ( Figs. 17-24). Leukocyte concentrates

from peripheral blood, obtained before surgery, revealed the presence of only

1 large binucleated cell. The day after surgery 2 binucleated cells and 1 large

atypical mononuclear cell with vacuoles were found; no Stemberg-Reed cells

were seen.

Pathologic examination of the spleen revealed gross infiltration by Hodgkins

disease. The spleen weight was 919 Gm. Microscopic examination of the spleen

revealed generalized infiltration by Hodgkin’s disease ( Fig. 25).

Special search for the presence of Sternberg-Reed cells in the capillary

vessels of the spleen revealed that many of the sinusoidal vessels of the spleen

contained large atypical reticulum cells which may possibly represent Stern-

berg-Reed cells.

Similar studies done on patient 2 revealed neither abnormal cells nor Stern-

berg-Reed cells in either the splenic artery or the splenic vein samples. In the

samples obtained after mechanical squeezing of the spleen, 22 abnormal cells

and 4 Stemberg-Reed cells were present. Patient 3 showed no abnormal cells

present in the sample obtained from the splenic artery, and 10 abnormal cells

were found equally divided between the splenic vein samples obtained directly

and after squeezing of the spleen.

As control studies, similar splenic samples were obtained in 3 splenecto-

mized patients, 2 of idiopathic thrombocytopenic purpura and 1 of hereditary

spherocytosis. No abnormal cells or Stemberg-Reed cells were found in either

the splenic artery or splenic vein samples obtained before and after manual

s(�ueezing of the spleen. The only occasional large cells found had the morpho-

logic characteristics of histiocytes. Similar cells were also found in the splenic

studies of the splenectomized patients with Hodgkin’s disease ( Fig. 5).

Dis�ussiox

The presence of Stemberg-Reed cells in routine smears of patients with

Hodgkin’s disease is extremely rare. In numerous periodic observations of a

total of 890 patients in our institution, over the past 15 years, such cells were

found only on 2 occasions, or 0.2 per cent. In the world’s literature, only 8

isolated cases have been reported.�’

The presence of Sternberg-Reed cells in routine needle bone marrow aspira-

tions is also rare. In our institution Sternberg-Reed cells have been found in

routine examinations of the bone marrow in 43 of 890 patients studied, or 4.8

per cent. These findings agree with other reports.2’2’ This is probably due to

the scattered focal lesions which may not be aspirated by the sternal needle

and also because the specific lesions in the hone marrow tend to have much

fibrous tissue, making their aspiration more difficult. This explains the practi-

cally constant finding of Hodgkin’s invasion of bone marrow in fatal autopsy

cases.--

The periodic examination of the leukocyte concentrates in 135 patients with

Hodgkin’s disease, conducted over the past 4 years in our laboratory, has




STERNBERC-REED CELLS

I, 23r -�

1”

551

Plate 3.-Leukocyte concentrate of splenic vein samples from patients with Hodg-kin’s disease. Sternberg-Reed cells: Fig. 1 7: Two cells in same field. Fig. 18: Cellwith indented nucleous and cvtoplasmic vacuoles. Fig. 19: Cell with cvtoplasmicvacuoles. Fig. 20: Mononuclear cell with prominent large nucleoli and cvtoplasmic

vacuoles. Fig. 21: Mononuclear cell with large nucleoims and promninemit miucleoli. Fig.

22: Multinucleated. Fig. 23: Multilobulated. Fig. 24: Binucleated with irregular

cvtoplasmic membrane and vacuoles. Magnification for Fig. 17 redtmced 20 per cent

from 2000 X; magnification for Figs 18-24 reduced 20 per cent from 2400 x.




Fig. 25.-Patient 1. Microphotograph of spleen showing areas of infiltration byHodgkin’s disease. Magnification 318 X.


revealed the presence of abnormal cells in 50 patients, or 37 per cent. Of this

group, 25 ( 18.5 per cent) also revealed the presence of typical Sternberg-Reed

cells sometime during the course of their illness. A few reports of similar

results in small numbers of patients have been published.8”3”4

The cells we have classified and described previously as abnormal cells

resemble morphologically transitional forms from reticuloendothelial cells. In

previous studies we have supported the view that Sternberg-Reed cells derive

from the reticuloendothelial system, and we have described transitional forms

in electron microscopy observations of lymph nodes of patients with Hodgkin’s

disease.’5 This view is generally accepted.m�m4

The abnormal or transitional cells were found mainly during the time of

activity of Hodgkin’s disease, but on some occasions they were also present

during periods of clinical remission. The Sternberg-Reed cells were found only

in patients with generalized advanced stages of Hodgkin’s disease. In 17 of the

25 patients, these cells were found from 4 months to 1 day prior to death.

However, 7 patients still responded to therapy and obtained further remissions

of from 1#{189}to 3 years duration. Three of the 7 obtained even longer remissions

since they are still alive and continuing to respond to therapy. Consequently,

the presence of Stemberg-Reed cells in the peripheral blood must be consid-

ered as indicating an advanced stage of the disease but not necessarily predict-

ing an immediately fatal outcome.




STERNBERG-REED CELLS 553

In spite of the fact that the technic employed in our study was qualitative,

the incidence of abnormal or transitional cells and Sternberg-Reed cells has

been as high as 40 cells per total number on periodic observations per each

individual patient and from 1 to as many as 30 cells per 5 ml. sample per

individual patient. It is then apparent that the total Sternberg-Reed cells and

transitional cells in the peripheral blood must, at times, be quite high.

Both the abnormal or transitional cells and the typical Sternberg-Reed cells

were found individually isolated in the leukocyte concentrate smears, in con-

trast to cancer cells which are usually found in clusters. The viability of the

exfoliated cells and the ability to overcome the patient’s defenses to form

metastases were not studied.

In some patients who responded to therapy, the Sternberg-Reed cells disap-

l)eared from the peripheral blood. However, this has occurred in some in-stances despite any objective evidence of a remission. It is also important to

emphasize that in our group of 135 patients, 85 (63 per cent) gave negative

findings. Nineteen of the negative patients had far-advanced disease, and they

did not clearly differ in terms of clinical or laboratory findings from the similar

positive group. In some of them, even determinations obtained immediately

prior to death were negative.

It is possible to hypothesize that in patients with active Hodgkin’s disease

Sternberg-Reed cells, transitional cells, other abnormal cells and monocytes are

stimulated in their production from cells of the reticuloendothelial system, in

the lymph nodes, spleen, liver and other organs of the reticuloendothelial

system. The stimulating agent which initiates this process is presently un-

known. However, the production of these various cells from the reticuloendo-

thelial system seems to increase simultaneously. These cells gain entry into the

general circulation. The reason the number of Sternberg-Reed cells is very

small and frequently absent in the peripheral blood is that their large size

militates against their remaining in circulation. They are presumably filtered

by the capillaries of the lungs. Only those cells which escape the first filtering

effect of the capillaries would be found transiently in the peripheral blood. The

concept of a filtering action by the lungs of large cellular elements which may

gain entrance into the general circulation is one which was suggested by

Aschoff23 and applied by Kiyono to the explanation of the low histiocyte count

in arterial blood.24 Simpson25 has demonstrated this same phenomenon to be

true for macrophages in experimental studies done in rabbits. The monocytes,

due to their smaller size, are able to circulate in the peripheral blood and are

found to be markedly increased during the active or advanced stages of Hodg-

kin’s disease.

This hypothesis is further supported by our studies on the incidence of

Stemberg-Reed cells and abnormal or transitional cells in the three splenec-

tomized patients with Hodgkin’s disease. Samples of circulating blood ob-

tained at the time of surgery showed no Sternberg-Reed cells in the samples

obtained from the splenic artery. However, they were present in the samples

obtained from the splenic vein, and in greater number in the samples obtained




554 BER’rIIA A. BOURONCLE

from the splenic vein after manual squeezing of the spleen. Because of the

distribution of the circulation of the spleen, it is possible that the Sternberg-

Reed cells and transitional cells, after they have reached the spleen or after

they are produced in the spleen, find easier access to the circulation. This

might also explain the higher incidence of Sternberg-Reed cells in the periph-

eral blood of patients who had abdominal involvement with Hodgkin’s

disease. In view of their higher circulating number more cells are able to

escape the effect of the capillary filtration. The microscopic study of the path-

ologic sections of the spleen from these patients confirmed the presence of

large atypical reticulum cells inside the splenic veins.

It should be emphasized that the search for Sternberg-Reed cells in the

leukocyte concentrates of patients with Hodgkin’s disease is essentially a re-

search technic and should not he considered as a screening test for Hodgkin’s

disease or a definite prognostic test.

SUMMATIY

Our observations of 135 patients indicate that 37 per cent of those suffering

from Hodgkin’s disease exhibit abnormal cells in the leukocyte concentrates of

the peripheral blood during the course of their illness. Typical Sternberg-Reed

cells were found in 18.5 per cent of patients and were present only in the

advanced stages of generalized Hodgkin’s disease.

The presence of Sternberg-Ileed cells in the peripheral blood indicates an

advanced stage of the disease l)ut does not necessarily predict an immediately

fatal outcome.

Comparative studies, searching for Sternberg-Reed cells in the splenic circu-

lation, showed no Sternberg-Reed cells to he present in the splenic arteries of

patients with Hodgkin’s disease; but numerous Sternberg-Reed cells were pres-

ent in the splenic vein, particularly after mechanical squeezing of the spleen.

A possible hypothesis is given to support the evidence for the circulation of

Sternberg-Reed cells and an explanation for their lower incidence in the pe-

ripheral blood.

Our observations support the hematogenous metastasis of Hodgkin’s disease.

SUMMARIO IN INTERLINCUA

Nostre observationes in 135 patientes indica que 37 pro centa del casos de

morbo de Hodgkin es characterisate durante Ic curso clinic per cellulas

anormal in le concentratos leucocytic dcl sanguine peripheric. Typic cellulas

de Steriiberg-Reed esseva trovate in 18,5 pro cento del patientes e esseva

presente solmente in le stadios avantiate de generalisate morbo de Hodgkin.

Le presentia de cellulas de Sternberg-Reed in Ic sanguine peripheric indica

tin stadio avantiate del morbo sed non predice necessarimente un imminente

exito mortal.

Studios comparative, cercante cellulas de Sternberg-Reed in Ic circulation

splenic, revelava nulle tales in Ic arterias splenic de patientes con morbo de

Hodgkin, sed numerose cellulas de Sternberg-Reed esseva presente in le vena

splenic, particularmente post compression mechanic del splen.




STERNBERC-REED CELLS 555

Es formulate un hvpothese in supporto del evidentia pm Ic circulation de

cellulas de Sternberg-Reed e un explication pro br plus basse incidentia in Ic

sangtmine peripheric.

Nostre observationes supporta le conception del metastase hematogene de

morbo de Hodgkin.

ACKNOWLEDGMENTS

We are grateful to Doctors Charles A. Doami and Jacob \V. Old for their suggestions ammd

review of this manuscript.

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1966 27: 544-556

BERTHA A. BOURONCLE and Rosemary Mann DiseaseSternberg-Reed Cells in the Peripheral Blood of Patients with Hodgkin's

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