PMC4137732_01
Computer tomography of the abdomen showing multiple intra-abdominal/pelvic masses and massive ascites.
CRIHEM2014-619760.001.jpg
PMC4137732_01_CRIHEM2014-619760.001.jpg
fig1
Bilateral pleural effusions were also seen (Figure 1).
(a) 100x H&E image shows a monomorphic infiltrate of small round blue cells with adjacent necrosis, (b) 400x H&E high power demonstrates medium sized cells with admixed apoptotic bodies and mitotic figures reminiscent of Burkitt or a Burkitt-like lymphoma, and (c) Ki-67: high proliferation rate over 90% supports the morphologic impression and is indicative of an aggressive lymphoma.
CRIHEM2014-619760.002.jpg
PMC4137732_01_CRIHEM2014-619760.002.jpg
fig2
The ki-67 proliferation rate was 95% (Figure 2), findings consistent with a high grade lymphoma such as Burkitt's or a B-cell lymphoma, unclassifiable with features intermediate between diffuse large diffuse B-cell lymphoma and Burkitt lymphoma.
(a) Flow cytometry of the ungated specimen of the abdominal mass showing a Cd45 bright population, compatible with a lymphoproliferative process (rather than a carcinoma, melanoma, etc.), (b) gating only the CD45 bright/low side scatter population shows a predominant CD20+/CD10+ population, consistent with a B-cell population of germinal center origin, and (c) light chain expression shows lambda light chain restriction, diagnostic of a B-cell lymphoma.
CRIHEM2014-619760.003.jpg
PMC4137732_01_CRIHEM2014-619760.003.jpg
fig3
Flow cytometry of the abdominal mass was also suggestive of an aggressive B-cell lymphoma (Figure 3).
FISH analysis using Abbott Tri-color Dual fusion Translocation Probe hybridized to a nucleus revealing, (a) an IgH/c-myc rearrangement by the juxtaposition of the red (c-myc) and green (IgH) yielding the yellow fusion. One native c-myc (red) and native IgH (green) are also present; (b) a BCL-2/IgH rearrangement by the juxtaposition of the red (BCL-2) and green (IgH) yielding the yellow fusion. One native BCL-2 (red) and native IgH (green) are also present.
CRIHEM2014-619760.004.jpg
PMC4137732_01_CRIHEM2014-619760.004.jpg
fig4
Subsequent FISH testing was positive for t(8;14), c-myc-IgH translocation, and a t(14;18) IgH-BCL2 translocation (Figure 4).
WHOLE BODY PET-CT showing multiple areas of hypermetabolic activity in the abdomen with hypermetabolic bony lesions suspicious of extensive metastatic disease.
CRIHEM2014-619760.005.jpg
PMC4137732_01_CRIHEM2014-619760.005.jpg
fig5
Multiple foci of hypermetabolic activity throughout the bones, suspicious for osseous metastatic disease, were also noted (Figure 5).
(a) Flow cytometry of the ungated bone marrow aspirate shows 16% cellularity in the CD45 bright/low side scatter gate, (b) gating only the CD45 bright/low side scatter gate shows a population of CD10+/CD20+ lymphocytes representing 7% of overall cellularity, and (c) this population shows dim surface lambda light chain restriction, all findings consistent with a low grade lymphoma of germinal center origin.
CRIHEM2014-619760.006.jpg
PMC4137732_01_CRIHEM2014-619760.006.jpg
fig6
The corresponding flow cytometry (Figure 6) demonstrated clonality with a lambda restricted CD20+/CD10+ population consistent with a low grade B-cell lymphoma with a germinal center phenotype.