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Hematopathology
Monday, February 28, 2005 - 7:30 PM
Convention Center, Ballrooom B
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Moderator:
John 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
Submitted by:
Marsha C. Kinney
University of Texas
San Antonio, TX
This 57 year-old female presented in March 2004 with a several week history of a 1.5 x 1.0 cm focally
ulcerated, nodular lesion on the right elbow. There was no past history of similar lesions or any
other pertinent disease process. The clinical impression was a pyogenic granuloma. A pathologic
diagnosis was rendered, and the lesion was totally excised and treated with local irradiation to the
area. Within a few weeks, new lesions developed on the left elbow and the left upper arm. The skin
of the right elbow was free of disease.
The patient was referred to a university hospital in July, 2004 where she was noted to have a > 1 cm
lesion on the left upper arm and several plaques with satellite nodules on the left elbow. The
largest lesion measured 2 x 1.3 cm and the satellite nodules measured from 0.6-1.0 x 0.5-0.7 cm.
There was no lymphadenopathy or hepatosplenomegaly. The skin lesions were totally excised. The
specimen for review is from one of the satellite lesions on the left elbow. CT scans were negative.
Bone marrow examination was not performed.
Case 1 - Figure 1 - Skin biopsy shows a dense lymphoid infiltrate extending from the superficial through the deep dermis to the subcutaneous tissue (H&E, original magnification X20).
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Case 1 - Figure 2 - The epidermis has pseudoepitheliomatous hyperplasia (H&E, original magnification X40).
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Case 1 - Figure 3 - The epidermis is focally ulcerated (H&E, original magnification X100).
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Case 1 - Figure 4 - The lymphocytes are predominantly large. Small lymphocytes surround the tumor mass and focally infiltrate the epidermis (H&E, original magnification, X400).
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Case 1 - Figure 5 - The large lymphocytes have dysplastic, large, folded, indented or U-shaped nuclei with dispersed chromatin, prominent nucleoli, and abundant eosinophilic cytoplasm. Small lymphocytes with somewhat irregular, hyperchromatic nuclei focally infiltrate the epidermis (H&E, original magnification X600).
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Case 1 - Figure 6 - The tumor cells have a sheet-like growth pattern and numerous mitotic figures are present (H&E, original magnification X600).
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Case 1 - Figure 7 - The large dysplastic lymphocytes and the small lymphocytes are CD3+ T-cells (Clone PSI, Novocastra, paraffin immunoperoxidase, original magnification X60).
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Case 1 - Figure 8 - The large dysplastic lymphocytes are CD4+ T-cells (Clone 1F6, Novocastra, paraffin immunoperoxidase, original magnification X600).
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Case 1 - Figure 9 - Scattered small lymphocytes are CD8+, and the large dysplastic lymphocytes are CD8 negative. Most of the small lymphocytes at the edges of the tumor mass and infiltrating the epidermis (as shown in Figure 4) are CD8+, reactive lymphocytes (not illustrated in this image) (Clone C8/144B, Dako Cytomation, paraffin immunoperoxidase, original magnification X600).
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Case 1 - Figure 10 - The lymphocytes are strongly CD30+ in a sheet-like distribution. (Clone BerH2, Neomarker, paraffin immunoperoxidase, original magnification X100).
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Case 1 - Figure 11 - Virtually all of the large lymphocytes are strongly CD30+ with a membrane and Golgi pattern of staining (Clone BerH2, Neomarker, paraffin immunoperoxidase, original magnification X600).
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Case 1 - Figure 12 - The epidermis strongly expresses epithelial membrane antigen (EMA) and the large lymphocytes are EMA- (Clone E29, Dako Cytomation, paraffin immunoperoxidase, original magnification X600).
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Case 1 - Figure 13 - Some of the large lymphocytes and scattered small lymphocytes have cytoplasmic expression of the cytolytic granule protein TIA-1. (Clone 2G9, Immunotech, paraffin immunoperoxidase, original magnification X600).
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Case 1 - Figure 14 - The large lymphocytes lack expression of anaplastic lymphoma kinase (ALK) protein. (Clone ALK01, Ventana, paraffin immunoperoxidase, original magnification X600).
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Submitted by:
Paul J. Kurtin
Mayo Clinic
Rochester, MN
The patient is a 43 year old male who sought medical attention for skin lesions. He reported a 2
month history of progressive red/dusky, nodules on the lower legs. Recently, he developed periodic
fevers to 39°C. There was no reported trauma to the legs. At the time of the physical
examination he was afebrile. He had multiple indurated dark red nodules on both legs:
Lymphadenopathy, splenomegaly and hepatomegaly were not detected.
His complete blood count, blood glucose, alpha-1-antitrypsin level, liver enzymes levels, and lactate
dehydrogenase level were all normal. He had no antecedent history of an autoimmune disorder
A biopsy of one of the lesions was performed. The slides and digital images are from the histology of
the biopsied lesion. Microbiologic cultures from the lesions grew no organisms.
Case 2 - Figure 1 - A mixed population of lymphocytes and histiocytes infiltrates the lobules and septa of the subcutaneous fat. Hematoxylin and eosin, 100X.
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Case 2 - Figure 2 - Abnormal medium size lymphocytes and histiocytes are present surrounding the adipocytes. Note the apoptotic debris within some of the macrophages. Hematoxylin and eosin, 200X.
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Case 2 - Figure 3 - The abnormal lymphocytes have irregular, hyperchromatic nuclei with inapparent nucleoli, and sparse cytoplasm. They rim the fat spaces and are mixed with macrophages with twisted nuclei, delicate chromatin, single nucleoli and abundant clear cytoplasm. Some of the macrophages contain apoptotic debris. Hematoxylin and eosin, 600X.
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Case 2 - Figure 4 - The neoplastic lymphocytes are positive for CD2. Immunoperoxidase stain for CD2, 200X.
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Case 2 - Figure 5 - The neoplastic lymphocytes express CD8. Immunoperoxidase stain for CD8, 200X.
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Case 2 - Figure 6 - Granzyme B positive lymphoma cells rim the fat spaces and are present between fat cells. Immunoperoxidase stain for granzyme B, 600X.
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Submitted by:
Mark R. Wick
University of Virginia Health Science Center
Charlottesville, VA
A 36 year old woman developed a slowly-enlarging red-blue nodule in the skin of the right earlobe. It
was asymptomatic, and the patient felt otherwise well. Physical examination disclosed no evidence of
lymphadenopathy or organomegaly, and there were no peripheral blood abnormalities. A punch biopsy of
the lesion was performed.
Case 3 - Figure 1 - This clinical photograph shows a violaceous nodular lesion of the right earlobe.
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Case 3 - Figure 2 - In this photomicrograph, one sees a vaguely nodular lymphoid infiltrate that occupies much of the dermis.
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Case 3 - Figure 3 - A partially follicular nature for the lymphoid infiltrate is better-seen in this photograph.
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Case 3 - Figure 4 - The lymphoid infiltrate is polymorphous in this area.
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Case 3 - Figure 5 - Notable stromal vascularity is apparent. The lymphoid cells in this field demonstrate modest nuclear atypia.
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Submitted by:
Randy D. Gascoyne
University of British Columbia
Vancouver, BC, Canada
A 74 year old man presented in 1988 with a raised, red skin mass involving his scalp. Following a
skin biopsy (submitted slides), complete lymphoma staging was performed. This revealed a normal LDH
and performance status and a negative bone marrow examination. FISH studies for the t(14;18) were
negative, but IGH PCR revealed a monoclonal B cell population.
He was diagnosed as stage 1AE and treated with radiotherapy alone. He did well and remained
lymphoma-free for nine years. In 1997 he died of unrelated causes resulting from circulatory
compromise associated with non-insulin dependent diabetes.
Case 4 - Figure 4 - CD3 stain of cutaneous follicular lymphoma.
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Case 4 - Figure 5 - CD21 stain of cutaneous follicular lymphoma. Note the tight meshworks of follicular dendritic cells.
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Case 4 - Figure 6 - CD10 stain of cutaneous follicular lymphoma showing strong expression.
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Case 4 - Figure 7 - Bcl-6 stain of cutaneous follicular lymphoma showing weak but definite staining of neoplastic B cells.
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Case 4 - Figure 8 - Bcl-2 staining of this case with strong expression.
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