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Hematopathology
Wednesday, March 5, 2008 , 7:30 PM
Convention Center 102/104/106More than Meets the Eye
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Moderator:
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MARSHA KINNEY
University of Texas Health Science Center
San Antonio, TX
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Clinical histories are displayed below.
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Submitted by: James R. Cook - Cleveland Clinic, Cleveland, OH
A previously healthy 26 year old man first came to clinical attention for a thyroid nodule. FNA of the thyroid mass was positive for papillary carcinoma, and a total thyroidectomy was scheduled. A pre-operative CBC and peripheral smear review (Figure 1) demonstrated the following results:
CBC 20.65 x103/µL
RBC 4.87 x106/µL
Hgb 15.2 g/dL
HCT 43.7 %
MCV 89.7 fL
PLT 183 x103/µL
Differential:
Abs Neut 2.68 x103/µL
Abs Lymph 4.34 x103/µL
Abs Mono 0.21 x103/µL
Abs Eo 13.42 x103/µL
Abs Baso 0.00 x103/µL
To evaluate the patient's marked eosinophilia, a bone marrow aspirate and biopsy were performed. The bone marrow aspirate (Figures 2, 3 and 4) differential count revealed:
2% Blasts; 3% Promyelos; 45% Myelos/Metas/Bands/Segs; 13% Eos; 0% Basos; 0% Monos; 14% Erythroids; 22% Lymphs; 1% Plasma cells
The bone marrow core biopsy demonstrated a 70% cellular bone marrow with trilineage hematopoiesis and eosinophilia (Figures 5, 6, and 7). No focal lesions were identified in routine sections. Immunohistochemical stains demonstrated mildly increased, scattered tryptase-positive mast cells that appeared spindled with coexpression of CD25 (Figure 8).
Case 1 - Slide 1
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Submitted by: L. Jeffrey Medeiros - University of Texas, M.D. Anderson Cancer Center, Houston, TX
An 11-year-old girl developed abdominal pain and physical examination revealed enlarged cervical lymph nodes. Biopsy of one lymph node was considered atypical paracortical hyperplasia without a specific diagnosis rendered. Bone marrow examination showed hypercellularity, myeloid hyperplasia, and eosinophilia. The patient was then referred to another hospital.
At time of transfer, the complete blood count showed normal hemoglobin and platelet counts and a leukocyte count of 19,000 with 10% eosinophils. Imaging studies showed cervical and retroperitoneal lymphadenopathy. A second cervical lymph node was biopsied at this time. In retrospect, the initial lymph node biopsy specimen was also involved by the same process. Immunohistochemical studies were performed and a number of markers were assessed with the following results: CD2+, CD4-, CD5+, CD7+, CD8-, Ig-, CD19-, and CD20-. (Additional markers are illustrated.) Conventional cytogenetic analysis was performed previously on bone marrow aspirate material and again on the second cervical lymph node specimen. The results showed a normal karyotype, 46, XX, in both specimens.
Case 2 - Slide 1
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Submitted by: Ahmet Dogan - Mayo Clinic, Rochester, MN
The patient was a 38 year-old male who was in excellent health until he developed some irritable bowel type symptoms in late 2003. He sought medical attention in July of 2005 because of the peripheral edema that he noted beginning in the spring of 2005. He also noted that he had some progressive shortness of breath over this period of time. CT scans of the abdomen and pelvis and chest and neck were performed. These studies demonstrated splenomegaly (14 cm AP and 18 cm cranial caudal). Also noted were scattered peri-aortic and mesenteric lymph nodes throughout ranging between 5 and 9 mm and bilateral axillary and mediastinal adenopathy with lymph nodes less than 1 cm in diameter.
An axillary lymph node biopsy was performed.
Case 3 - Slide 1
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Submitted by: Steven H. Swerdlow - University of Pittsburgh Medical Center, Pittsburgh, PA
An 88-year-old woman who hit her head on the sink when she bent to pick up a brush and developed a lump on her forehead. Initial CT was interpreted as a small left frontal scalp hematoma. She had persistent shoulder/neck pain, went to the ER and her shoulder was injected with steroids and she was given oral steroids as well. After some pain relief, the patient presented again 4 weeks following her injury to the hospital with diplopia, a persistent "hematoma" and severe neck pain. Following a repeat CT and an MR, an excisional biopsy was performed and is submitted for your review. Flow cytometric immunophenotypic studies demonstrated a CD5-, CD10-, CD20+, kappa monoclonal population with admixed heterogeneous T-cells.
Case 4 - Slide 1
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