PMC5632856_01
Peripheral blood examination. (a) The patient's peripheral blood smear shows leukocytosis with neutrophilia, left shift, and toxic granulation (Wright's stain, 40x). (b) Scattered medium size atypical cells are present. These cells feature prominent nuclear irregularities and vacuoles (Wright's stain, 100x oil). (c) Atypical cells have pseudopodial cytoplasmic projections (Wright's stain, 50x oil).
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The peripheral blood smear showed severe neutrophilia with toxic granulation and a small number of atypical lymphocytes (Figure 1).
Peripheral blood and bone marrow aspiration analyzed by flow cytometry. Flow cytometry analysis of peripheral blood (a) and bone marrow (b) revealed a similar small population of atypical lymphocytes (red) which are positive for CD45 and CD7 and negative for CD2, CD3, CD4, CD5, CD8, CD16, CD56, and CD57. Normal T-cells are in blue and normal natural killer cells are in green.
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Flow cytometric analysis of peripheral blood (Figure 2(a)) revealed a small population of abnormal T-cells, which was positive for CD45 and CD7, but negative for CD2, CD3, CD4, CD5, CD8, CD16, CD56, and CD57. The flow cytometric analysis of the bone marrow aspirate (Figure 2(b)) showed a small T-cell population (3.7% of marrow nucleated cells) with identical immunophenotypic features to those in peripheral blood.
Laboratory parameters along the patient's clinical course. White blood cells (WBC), absolute neutrophil counts, lymphocyte counts, renal and liver function tests, and lactic acid and lactate dehydrogenase (LDH) levels are shown.
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Her laboratory parameters along her clinical course are shown in Figure 3.
Morphological features of bone marrow core biopsy and aspiration. The H&E section of bone marrow core biopsy demonstrated hypercellularity for the patient's age with myeloid hyperplasia ((a) 100x magnification; (b) 400x magnification). Scattered lymphoma cells (pointed by the white arrows) were easily seen on aspirate smears ((c) Wright's stain, 1000x magnification) but not easily discernible on H&E sections.
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Bone marrow core biopsy revealed hypercellularity with loose clusters of small to medium sized neoplastic cells, accounting for 5-10% of the marrow cellularity (Figures 4 and 5).
Immunohistochemistry staining of bone marrow core biopsy. Small to intermediate sized neoplastic cells form loose clusters and comprise 5-10% of marrow cellularity. These cells stain positive for CD30 (a, e), CD7 (b, f), EMA (equivocal) (c, g), and ALK (d, h). (a-d) 100x magnification; (e-h) 1000x magnification.
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Bone marrow core biopsy revealed hypercellularity with loose clusters of small to medium sized neoplastic cells, accounting for 5-10% of the marrow cellularity (Figures 4 and 5). The immunohistochemistry studies of the core biopsy revealed that lymphoma cells expressed CD30 (strong), CD7 (strong), and ALK (cytoplasmic) (Figure 5).
Representative autopsy sections from spleen and lung. Lymphoma cells were not overtly discernible on H&E section ((a) 100x magnification) but clearly identified by immunostains ((b) CD30 staining) in the spleen. In the lung parenchyma, lymphoid infiltrates were prominent with predominantly small to medium sized cells (H&E staining; (c) 100x magnification; (d) 400x magnification). Intravascular lymphoma involvement was evident morphologically ((e) H&E staining, 400x magnification) and confirmed by immunostains ((f) CD30, 200x magnification). Black arrowheads in (e) refer to intravascular lymphoma involvement.
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Autopsy showed diffuse microscopic lymphoma infiltration of the spleen (Figures 6(a) and 6(b)), lung (Figures 6(c) and 6(d)), and liver. Intravascular lymphoma involvement was present in both brain and lung (Figures 6(e) and 6(f)).
Cytogenetic analysis of bone marrow. (a) The G-banded metaphase cell demonstrates abnormalities involving chromosomes 2 and 22 (black arrows), interpreted to represent an initial chromosome 2 pericentric inversion that disrupts the ALK gene at band 2p23 and translocates the centromeric portion of the gene to band 2q22. This is followed by a translocation between the inverted chromosome 2 (with a breakpoint distal to the ALK gene) and chromosome 22q. The karyotype is designated as 46,XX,inv(2)(p23q22)t[inv(2);22)(p24;q12)]. (b) Fluorescence in situ hybridization (FISH) utilizing an ALK gene break-apart probe demonstrates disruption of the gene (white arrow) and relocation of the centromeric portion of the gene to the long arm of chromosome 2 (white arrow head) as a result of the chromosome 2 pericentric inversion.
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Bone marrow cytogenetic evaluation identified an unusual chromosome 2 inversion [inv(2)(p23q22)] resulting in ALK gene rearrangement, as well as a translocation involving the inv(2) chromosome with chromosome 22q (Figure 7(a)); however, fluorescence in situ hybridization (FISH) studies demonstrated that the ALK gene was not involved in the translocation with chromosome 22 (Figure 7(b)).