Virtual Slidebox
Presented by the MGH Pathology Service

Clinical history:

43 year old woman with anemia and thrombocytopenia. WBC: 17,400 (28% blasts, 40% lymphocytes, 17% monocytes, 12% neutrophils, 3% eosinophils).

Cytogenetics:

inv(16) – This cytogenetic abnormality can be very subtle. FISH should be ordered on cases with morphologic features of inv(16) and reportedly normal karyotypes, as this finding may influence therapy.

Read more on Acute myeloid leukemia with inv(16) (bone marrow – aspirate)…

Clinical history:

43 year old woman with anemia and thrombocytopenia. WBC: 17,400 (28% blasts, 40% lymphocytes, 17% monocytes, 12% neutrophils, 3% eosinophils).

Clinical history:

37 y/o female. WBC 108.7, Hct 27.4, Plt 163. Molecular testing positive for NPM1 mutation and FLT3 ITD mutation.

Bone marrow aspirate:

Bone marrow aspirate – Maturing erythroid cells comprise >50% of the marrow population, and blasts comprise >20% of the non-erythroid population.

Read more on Acute myeloid leukemia with mutated NPM1 (morphologically FAB M5B)…

Clinical history:

31 year old woman with anemia and thrombocytopenia. WBC: 9,400, no differential provided.

t(8;21) – This translocation involves RUNX1 (also known as AML1 or CBFA) at 21q22 and RUNX1T1 at 8q22. This finding defines AML, even in the absence of sufficient blasts in the marrow or PBL.

Read more on Acute myeloid leukemia with t(8;21) (bone marrow – aspirate)…

Clinical history:

31 year old woman with anemia and thrombocytopenia. WBC: 9,400, no differential provided.

Clinical history:

72 y/o female. WBC: 2.9, Hct: 24.2%, Plt: 29

Immunohistochemistry:

Clinical history:

61 y/o male. WBC 1.7, HCT 27.6, PLT 91.

Immunohistochemistry:

68 y/o male, 2 months status-post allogeneic BMT for AML.

Clinical history:

51 year old man with pancytopenia.

Cytogenetics:

t(15;17) – Fusion of the RARA (chr 17q12) and PML (chr 15q22) genes creates a fusion oncoprotein which defines APML, and mediates its responsiveness to all-trans retinoic acid (ATRA)

Read more on Acute promyelocytic leukemia, classic variant (bone marrow – aspirate)…

Clinical history:

51 year old man with pancytopenia.

Clinical history:

38 y/o M with enlarged neck node.

Immunohistochemistry:

CLINICAL FEATURES AND PATHOGENESIS
• Peak incidence in adults, age 40-65 years
• Primary to lymph nodes (most cases) or extranodal sites (bone, soft tissues, skin)
• Worse prognosis than Anaplastic large cell lymphoma, ALK+, but probably better than Peripheral T-cell lymphoma, not otherwise specified
MICROSCOPIC FEATURES
• Nodal or tissue architecture effaced by solid sheets of malignant cells, often within sinuses at the periphery
• Large, pleomorphic, mitotically active cells, often with prominent nucleoli and moderate to high N:C ratio
• Horseshoe-shaped “hallmark cells” or cells with wreath-like nuclei may be present.
ANCILLARY STUDIES
• Uniform, strong CD30+ and ALK-1 negative by definition
• Loss of pan T-cell markers is common, but usually at least one of CD2, CD3, CD5 or CD43 is positive.
• Often positive for EMA, CD4 and/or cytotoxic T-cell markers such as TIA1, granzyme B, and perforin
• Negative for Pax5, EBER, and usually CD15 (vs. CHL) and keratin (vs. carcinoma)
DIFFERENTIAL DIAGNOSIS
• Anaplastic large cell lymphoma, ALK positive
• Peripheral T-cell lymphoma, not otherwise specified
• Classical Hodgkin lymphoma (especially syncytical variants)
• Primary cutaneous anaplastic large cell lymphoma (in skin)
• Enteropathy-associated T-cell lymphoma (in GI tract)
REFERENCES
•WHO Classification of Tumors of Haematopoetic and Lymphoid Tissues, 4th edition

Read more on Anaplastic large cell lymphoma, ALK negative…

Clinical summary
52 yo M with skin nodule; also has multiple enlarged lymph glands

49 y/o female with a mediastinal mass

Clinical history:

54 y/o male with severe abdominal pain

Special stains & Immunohistochemistry:

Molecular testing:

FISH testing was positive for a rearrangement involving MYC at 8q24.

Clinical history:

33 year old man with severe fatigue. WBC: 1,200. HCT: 33%. PLT: 15,000.

Cytogenetics:

Hyperdiploid karyotype – The finding of >50 chromosomes defines a subcategory of B-ALL with a unique gene expression profile and good prognosis.

Read more on B-lymphoblastic leukemia with hyperdiploidy (bone marrow – biopsy)…

Clinical history:

21 y/o male. WBC 3.9 HCT 35.4, PLT 46

Bone marrow aspirate:

Monomorphic B-lymphoblasts comprise the majority of cells.

Clinical history:

Female in her 60’s with pancytopenia and skin lesions. Bone marrow biopsy

Immunohistochemistry:

Clinical history:

Female in her 60’s with pancytopenia and skin lesions. Skin over breast

Immunohistochemistry:

Clinical history:

56 year old man with weight loss and bleeding. WBC: 7,200 (10% blasts were identified at outside hospital).

Cytogenetics:

t(8;22) – This translocation involves the loci for MYC (8q24) and lambda light chain (22q11). It is less common in BL than the t(8;14), which involves the IGH locus.

Read more on Burkitt lymphoma (bone marrow – aspirate)…

Clinical history:

56 year old man with weight loss and bleeding. WBC: 7,200 (10% blasts were identified at outside hospital).

Immunohistochemistry:

Clinical summary
55 yo M with chest wall nodule (over the sternum)

MICROSCOPIC FEATURES

• Marked expansion of portal tracts by lymphocytic infiltrates. The extent of the infiltrate is beyond what is seen in chronic viral hepatitis, where portal tracts tend to have a relatively tight “cuff” of inflammation around them.
• The lymphocytic infiltrate is sheet-like and monotonous, rather than mixed and with a follicle-like architecture, as is usually seen in chronic viral hepatitis. In some cases, the lymphoid cells may show atypia.
• There is no interface hepatitis at the edge of the infiltrate, and there are no apoptotic hepatocytes in the lobule
• There is no associated periportal fibrosis, as is usually seen with the inflammatory infiltrates of chronic viral hepatitis

Read more on Chronic lymphocytic leukemia, involving liver…

Clinical history:

60 y/o female with WBC = 26

Bone marrow aspirate:

The majority of marrow cells are maturing or mature myeloids, with prominent populations of eosinopils and basophils also present.

Read more on Chronic myelogenous leukemia, chronic phase…

Clinical history:

42 year old man with fatigue, abdominal pain, and leukocytosis. WBC: 365,000. HCT: 18%. PLT: 568,000.

Cytogenetics:

t(9;22) – This translocation fuses portions of the genes BCR (22q11.2) and ABL (9q34), usually producing the p210 BCR-ABL fusion protein.

Read more on Chronic myelogenous leukemia, chronic phase (2)…

52 y/o female with diffuse lymphadenopathy, hepatosplenomegaly, and peripheral eosinophilia

29 y/o male with inguinal lymphadenopathy and peripheral eosinophilia

Clinical history:

23 y/o male with a left neck mass

Immunohistochemistry:

27 y/o male with axillary and cervical lymphadenopathy

MICROSCOPIC FEATURES

• Portal tracts are expanded by a mixed lymphoid infiltrate, which focally extends into the lobules
• The infiltrate contains lymphocytes, plasma cells, eosinophils, and scattered Reed-Stenberg cells
• The infiltrate may also involve bile ducts
• Sinusoidal dilatation and peliosis hepatis may also be present
• Epithelioid granulomas are found in ~10% of cases, usually in the portal tracts

Read more on Classical Hodgkin lymphoma, involving liver…

Clinical history:

40 yo M with enlarged right elbow lymph node.

Immunohistochemistry:

Clinical history:

68 y/o male with abdominal pain and a splenic mass

Immunohistochemistry:

75 y/o female with cervical lymphadenopathy

Clinical history

Female in her 70’s with pulmonary nodules, inguinal mass, weight loss. 2 HE. CD20, CD3. EBER, kappa lambda.

Immunohistochemistry

Clinical history

Female in her 70’s with history of DLBCL of tonsil s/p rx, now with duodenal obstruction.

Immunohistochemistry

Clinical history:

32 y/o male with refractory immune thrombocytopenic purpura

Immunohistochemistry:

Clinical history:

83 F with subconjunctival “salmon-colored” lesion.

Special stains:

Clinical history:

68 yo M with large supraglottic mass, found during evaluation for hoarseness

Immunohistochemistry & In-situ hybridization:

Female in her 40’s with a parotid mass

Clinical history:

Septal biopsy and excision of sinus contents in a 31 yo lady. Has had 2 prior biopsies in past year, both called “severe chronic rhinitis/rhinosinusitis.”

Additional H&E images:

Infiltration of the lymphoid cells into bone is highly suggestive of malignancy.

Read more on Extranodal NK/T Cell lymphoma…

Clinical history:

38 y/o female with cervical and axillary lymphadenopathy

Clinical history:

44 y/o male with posterior neck mass x 2 years, growing in size

Immunohistochemistry:

80 y/o female with abdominal pain

Adolescent male with lymphdenopathy

67 y/o female with mass in T9 vertebra

Male in his 70’s with a history of HIV and HCV infection and generalized lymphadenopathy

Clinical summary
26 yo M with sepsis and fever

19 yo F with 3 week history of tender enlarged inguinal lymph node, weight loss, fatigue and night sweats

Female in her 40’s with an enlarged, painful axillary lymph node

Immunohistochemistry:

Tibial lesion in young child

Clinical history:

12 yo F with tender lump on mid-occipital scalp, gradually increasing in size over 3 months. Mass extended into skull.

Immunohistochemistry: