PMC6308018_01
(a) Bone marrow aspiration revealed medium to large sized atypical lymphoma cells with indistinct nucleoli, basophilic cytoplasm and cytoplasmic vacuoles (May-Giemsa staining x1000). (b) Immunophenotyping panel at the initial presentation. (c-i) Bone marrow biopsy at the initial presentation showed widespread infiltration lymphoma cells (c) hematoxylin &E eosin x200). Lymphoma cells are positive for (d) CD20 (L26) x200, (e) CD79alpha x200, (f) BCL6 x400, (g) BCL2 x400, (h) MUM1 x400, but negative for (i) CD3 x200. (j) G-Banding chromosomal analysis of the bone marrow cells at the initial presentation demonstrated that 15 of the 20 cells analyzed showed complex chromosomal abnormalities, including 47, XX, -1, add (3) (q11.2), add (4) (q31), t(6;14) (p21;q32), del (8) (q22q23), ?t(9;14) (p13b;q32), add)12)(p11.2), der(12)add(12)(p13), add (12) (q22), der(15)t(1;15)(q11;p11.1)del(1)(q23q25), der(16)add(16)(p11.2) add(16)(q22),+18,add(20)(q11.2),+der(?)t(?;1)(?;p22).
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In contrast, bone marrow aspiration demonstrated widespread infiltration of medium to large sized atypical lymphoma cells with distinct nucleoli, basophilic cytoplasm, and cytoplasmic vacuoles, whose immunophenotyping revealed CD5-/CD10-/CD19+/CD20+/Igkappa+ (Fig. 1(a): May-Giemsa stain x1000, Fig. 1(b): Immunophenotyping panel). Bone marrow biopsy consistently revealed hypercellularity with widespread infiltration of large lymphoma cells positive for CD20 (L26), CD79alpha, BCL6, BCL2, MUM1, but negative for CD3 (Fig. 1, c: hematoxylin and eosin x200, d: CD20 x200, e: CD79alphax200, f: BCL6 x400, g: BCL2 x400, h: MUM1 x400, i: CD3 x200). C, CD34, c-kit, and terminal deoxyribonucleotidyl transferase (TdT). Cytogenetic analysis of the bone marrow cells demonstrated that 15 of the 20 cells analyzed showed complex chromosomal abnormalities; 47, XX, -1, add (3) (q11.2), add (4) (q31), t(6;14) (p21;q32), del (8) (q22q23), ?t(9;14) (p13b;q32), add(12)(p11.2), der(12)add(12)(p13), add (12) (q22), der(15)t(1;15) (q11;p11.1)del(1)(q23q25), der (16)add(16)(p11.2)add(16)(q22), +18, add(20) (q11.2), +der(?)t(?;1)(?;p22) (Fig. 1(j)).
(a)(b) Bone marrow biopsy at day 28 of the first cycle of R-CHOP therapy revealed complete clearance of CD20 positive atypical large lymphoma cells and commencement of resolution of the hemophagocytosis ((a) hematoxylin & eosin x200, (b) CD20 x200). (c) Chromosomal analysis at day 28 of the first cycle of R-CHOP therapy demonstrated 20 of the 20 analyzed cells showed normal karyotype and CR was attained. (d) Chromsomal analysis at 8 years after the initial presentation demonstrated 20 of the 20 analyzed cells showed normal karyotype and the patient has been in CR. (e) FDG/ PET at eight years after the initial diagnosis.
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She attained complete bone marrow response with no evidence of residual lymphoma cells in the bone marrow, assessed by immunohistochemistry on day 28 of the first cycle of the chemotherapy (Table 1, Fig. 2(a): hematoxylin and Eosin x200, b: CD20 x200) and chromosomal analysis showed normal karyotype (Fig. 2(c)). Currently, 8 years after the initial presentation, the patient has no signs of recurrence of lymphoma on the bone marrow survey including chromosomal analysis (Fig. 2(d)). Positron emission tomography (PET)/CT scan revealed slightly low 18F-FDG up-take which is considered to be associated with osteoporosis (Fig. 2(e)).