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Hematopathology
Cases that "taught me a lesson"
Wednesday, March 10, 2004 - 7:30 p.m.
Ballroom A
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Moderator:
JOHN B. COUSAR
University of Virginia Health System
Charlottesville, VA
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Clinical histories are printed below.
Click on the case numbers for text and references of each case.
Click on each slide thumbnail image for an enlarged view
SHERRIE L. PERKINS
University of Utah Medical Center
Salt Lake City, UT
This is a 26 year-old man who presented with a sore throat and an asymmetrically enlarged right tonsil
(although both tonsils appeared enlarged). He had no significant past medical history. He noted a 3
pound weight loss and low-grade fever for the past week. Physical examination revealed several
enlarged cervical nodes and a palpable liver edge. A tonsillectomy was performed.
Case 1 - Figure 1 - Low power photomicrograph of the right tonsil showing partial effacement of architecture and prominent large cell infiltrate, H&E X100
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Case 1 - Figure 2 - High power photomicrograph of right tonsil demonstrating large cell infiltrate and Reed-Sternberg-like cell, H&E 400X
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Case 1 - Figure 3 - High power photomicrograph showing diversity of interfollicular infiltrate and "mummified" apoptotic large cells, H&E 400X
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Case 1 - Figure 4 - Immunohistochemical stain for CD20 and CD3, 400X
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Case 1 - Figure 5 - Immunohistochemical staining for CD30, 400X
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Case 1 - Figure 6 - LMP (latent membrane protein) immunohistochemical staining and EBER in-situ hybridization demonstrating EBV virus, 400X
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WILLIAM R. MACON
Mayo Clinic
Rochester, MN
An 81-year old female presented with epigastric pain and was subsequently found to have a solitary
splenic mass on abdominal CT scan. The patient was followed for 7 months, during which time the
splenic mass gradually enlarged and developed central necrosis. Splenectomy was then performed, and
the 200g spleen had a well-circumscribed 6.5 cm mass. A gross photo of the mass, low and high power
H&E stained images, EBV in situ hybridization and an EBV Southern blot are shown.
Case 2 - Figure 1 - Cross-section of spleen demonstrating a fleshy mass that replaces much of the splenic parenchyma. There is central hemorrhage and necrosis.
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Case 2 - Figure 2 - Spleen, low magnification. The normal splenic tissue is well-demarcated from the mass by dense fibrous tissue.
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Case 2 - Figure 3 - Spleen, high magnification. Occasional spindle cells (arrow) are present within a background of numerous plasma cells, small lymphocytes, and histiocytes.
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Case 2 - Figure 4 - In situ hybridization for Epstein-Barr virus-encoded nuclear RNA1 and RNA2 shows strong and diffuse staining in the spindle cells.
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Case 2 - Figure 5 - Epstein-Barr virus Southern blot. Left to right. Lane 1 contains DNA from a negative control lacking EBV DNA. Lanes 2 and 4 contain positive control DNA from a clonal EBV-infected neoplasm diluted 1:10 and 1:1 with negative control DNA. Lane 3 contains the patient's DNA; the single high-intensity band indicates EBV monoclonality.
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DENNIS D. WEISENBURGER
University of Nebraska Medical Center
Omaha, NE
The patient is a 61-year-old male with generalized lymphadenopathy who is otherwise asymptomatic. He
underwent a right inguinal lymph node biopsy. The phenotype of the lymphoid cells is as follows:
CD3-, CD5+, CD10-, CD20+, CD23-, CD43-, cyclin D1-.
Case 3 - Figure 1 - Low power of lymph node showing a vaguely nodular pattern.
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Case 3 - Figure 2 - Medium power of lymph node showing a burnt-out germinal center that is surrounded and infiltrated by atypical lymphoid cells (mantle zone pattern).
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Case 3 - Figure 3 - Atypical lymphoid cells with irregular nuclei and scant cytoplasm, with a few histiocytes admixed.
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ERIC D. HSI
Cleveland Clinic Foundation
Cleveland, OH
A 42 y.o. woman with a remote history of Hodgkin lymphoma in 1988 presented to a surgeon in October of
2003 with new adenopathy. The patient was well until 6 months prior to this when she developed
axillary lymphadenopathy. She also reported having night sweats for the last month and pruritis.
Other than the history of lymphoma, her past medical history was not significant. Physical
examination showed axillary, cervical, and supraclavicular lymphadenopathy. A cervical lymph node was
biopsied. H&E images and CD15 and CD30 immunostains are shown. Shortly after the lymph node
biopsy was performed, a skin biopsy was also done. In the interim, a more detailed history and
physical was performed. Review of systems revealed a pruritic skin rash for 20 years and a dry cough.
Physical examination showed the previously mentioned lymphadenopathy and erythematous plaques on the
forearms and legs. A CBC was performed and showed a mild thrombocytosis (460 x 109/l) but was
otherwise normal.
Case 4 - Figure 1 - Lymph node biopsy, H&E, low magnification. Note effacement of lymph node and sclerosis.
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Case 4 - Figure 2 - Lymph node biopsy, H&E high magnification. A mixed infiltrate is present with lymphocytes, plasma cells, occasional eosinophils, and atypical large cells. Reed-Sternberg like cells are present.
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Case 4 - Figure 3 - Lymph node biopsy, H&E high magnification. A mixed infiltrate is present with lymphocytes, plasma cells, occasional eosinophils, and atypical large cells. Reed-Sternberg like cells are present.
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