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Presented by Michael Borowitz, M.D., Ph.D.. and prepared by Amy Duffield, M.D., Ph.D.
Case 4: 76 year old male with knee pain.
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Week 381: Case 4
76 year old male with knee pain. CBC showed Hgb 6.2 g/dl, WBC 17,000/ul, platelets 22,000/ul.images/Mantle 2B.jpg
images/Mantle 2C.jpg
images/Mantle 2D.jpg
images/Mantle 2E.jpg
images/Mantle 2F.jpgCorrect
Answer: Blastoid mantle cell lymphoma
Histology: The marrow core shows a monotonous infiltrate of blast like cells that suggest acute leukemia, and really by itself is not sufficient to establish the diagnosis. The clue to the lesion is in the touch prep, which shows agranular blast-like cells with blue cytoplasm and vacuoles.
Such morphology should always suggest a lymphoid origin. The cells are not uniform enough, nor is the cytoplasm deep enough blue to suggest Burkitt lymphoma/leukemia. While ALL is a possibility, as vacuoles may occasionally be seen, it is always a good idea, in an adult, to make sure that mantle cell lymphoma is considered in any case with unusual-appearing lymphoid blasts. The cyclin D1 stain establishes the diagnosis.
Discussion: Blastoid mantle cell lymphoma is generally considered more aggressive than ordinary mantle cell lymphoma, and occurs in two morphologic forms, one composed of cells resembling lymphoblasts, as seen here, and a second pleomorphic form with many large atypical cells that can mimic diffuse large B cell lymphoma. Leukemia (as opposed to lymphomatous) presentations may be seen, though are not as common as nodal presentations.
Incorrect
Answer: Blastoid mantle cell lymphoma
Histology: The marrow core shows a monotonous infiltrate of blast like cells that suggest acute leukemia, and really by itself is not sufficient to establish the diagnosis. The clue to the lesion is in the touch prep, which shows agranular blast-like cells with blue cytoplasm and vacuoles.
Such morphology should always suggest a lymphoid origin. The cells are not uniform enough, nor is the cytoplasm deep enough blue to suggest Burkitt lymphoma/leukemia. While ALL is a possibility, as vacuoles may occasionally be seen, it is always a good idea, in an adult, to make sure that mantle cell lymphoma is considered in any case with unusual-appearing lymphoid blasts. The cyclin D1 stain establishes the diagnosis.Discussion: Blastoid mantle cell lymphoma is generally considered more aggressive than ordinary mantle cell lymphoma, and occurs in two morphologic forms, one composed of cells resembling lymphoblasts, as seen here, and a second pleomorphic form with many large atypical cells that can mimic diffuse large B cell lymphoma. Leukemia (as opposed to lymphomatous) presentations may be seen, though are not as common as nodal presentations.
