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Presented by Risa Mann, M.D. and prepared by Angelique W. Levi, M.D.
Case 4: 54 year-old female with cervical and inguinal adenopathy
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1. Question
Week 17: Case 4
54 year-old female with cervical and inguinal adenopathy
Correct
Answer: Follicular lymphoma, grade I (small cleaved cell type)
Histology: The biopsy is of a lymph node which shows effacement of the architecture by a lymphoid proliferation which grows in a nodular pattern. The nodules are packed in a back-to-back fashion within the lymph node. The nodules are composed predominantly of small irregular cleaved lymphocytes. The nodules lack tingible body macrophages or evidence of polarization of the cells within the nodules.
Discussion: The major differential diagnosis in lymph nodes with a follicular growth pattern such as this includes various low grade lymphomas such as follicular lymphoma, mantle cell lymphoma and reactive atypical follicular hyperplasia. Occasionally, lymphocyte predominant Hodgkin’s disease may have a nodular pattern but the cells within the nodules are round and regular and do not have the cleaved appearance associated with follicular lymphomas. The distinction between follicular lymphoma and follicular hyperplasia can be made usually based on morphology. Reactive follicles show polarization of the cells within the germinal centers as well as numerous tingible body macrophages. Also, in reactive follicular hyperplasia, the nodules are often closer together and proliferate in a back-to-back fashion. The use of immunologic marker studies is extremely helpful in making this differential diagnosis. If flow cytometry is available it will show the presence of a clonal proliferation of B-cells, which are often CD10 positive in follicular lymphomas. If fresh tissue is not available stains for bcl-2 on the formalin fixed tissue can be helpful in this differential diagnosis. The neoplastic nodules in follicular lymphoma are positive for bcl-2 whereas the follicles in follicular hyperplasia are negative. This stain must be used with caution and with other marker studies. In particular, it is helpful to do a CD3 stain to identify T-cells which may be present within the nodules which would also stain with bcl-2. The bcl-2 positivity is a reflection of the characteristic rearrangement associated with this lymphoma which is a 14:18 translocation involving the bcl-2 oncogene.
Incorrect
Answer: Follicular lymphoma, grade I (small cleaved cell type)
Histology: The biopsy is of a lymph node which shows effacement of the architecture by a lymphoid proliferation which grows in a nodular pattern. The nodules are packed in a back-to-back fashion within the lymph node. The nodules are composed predominantly of small irregular cleaved lymphocytes. The nodules lack tingible body macrophages or evidence of polarization of the cells within the nodules.
Discussion: The major differential diagnosis in lymph nodes with a follicular growth pattern such as this includes various low grade lymphomas such as follicular lymphoma, mantle cell lymphoma and reactive atypical follicular hyperplasia. Occasionally, lymphocyte predominant Hodgkin’s disease may have a nodular pattern but the cells within the nodules are round and regular and do not have the cleaved appearance associated with follicular lymphomas. The distinction between follicular lymphoma and follicular hyperplasia can be made usually based on morphology. Reactive follicles show polarization of the cells within the germinal centers as well as numerous tingible body macrophages. Also, in reactive follicular hyperplasia, the nodules are often closer together and proliferate in a back-to-back fashion. The use of immunologic marker studies is extremely helpful in making this differential diagnosis. If flow cytometry is available it will show the presence of a clonal proliferation of B-cells, which are often CD10 positive in follicular lymphomas. If fresh tissue is not available stains for bcl-2 on the formalin fixed tissue can be helpful in this differential diagnosis. The neoplastic nodules in follicular lymphoma are positive for bcl-2 whereas the follicles in follicular hyperplasia are negative. This stain must be used with caution and with other marker studies. In particular, it is helpful to do a CD3 stain to identify T-cells which may be present within the nodules which would also stain with bcl-2. The bcl-2 positivity is a reflection of the characteristic rearrangement associated with this lymphoma which is a 14:18 translocation involving the bcl-2 oncogene.
