PMC8474063_01
The bone marrow biopsy showed nodular proliferation of neoplastic lymphocytes (A, H&E x 20). Immunohistochemistry revealed the lymphocytes positive for CD23 (B, x 20). Flow cytometry analysis confirmed lymphocytes positive for CD20 and predominantly negative for CD38 (C). FISH study revealed loss ofD13S319 signal, which indicated the deletion of 13q (D).
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Bone marrow biopsy (Figure 1A) showed nodular proliferation of neoplastic lymphocytes, immunohistochemistry (Figure 1B) revealed the lymphocytes positive for CD23, flow cytometry analysis (Figure 1C) confirmed lymphocytes positive for CD20 and predominantly negative for CD38, FISH study (Figure 1D) revealed loss of D13S319 signal, which indicated the deletion of 13q.
(A) Pretreatment CT imaging showed a left pelvic sidewall mass, pelvic mesenteric lymphadenopathy, and external iliac lymphadenopathy. (B). Pretreatment PET shows hypermetabolic pelvic lesion however unable to accurately measure SUVs in this mass due to concentrated radiotracer within the involved left ureter. (C). Pretreatment CT imaging showed associated left hydronephrosis. (D) Post treatment PET scan after 6 cycles of induction therapy showed low level metabolic activity within the left pelvic sidewall mass, SUV max 2.1, no evidence for recurrence.
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CT imaging showed a new left pelvic sidewall mass 7.6 cm in maximum transverse dimension (Figure 2A), hypermetabolic on PET however it was unable to accurately measure SUVs in this mass due to concentrated radiotracer within the involved left ureter (Figure 2B), there was also associated left hydronephrosis (Figure 2C), and increased pelvic mesenteric lymphadenopathy and external iliac lymphadenopathy. PET scan after completing cycle 6 showed complete remission with no evidence of disease activity (Figure 2D).
The core needle biopsy of the pelvic mass showed a diffusely infiltrating large atypical cells (yellow arrow) with intermixed clusters of small lymphocytes (black arrow) (A, H&E x 20). Immunohistochemical studies showed both small and large lymphocytes were strongly positive for CD20 (B, x 20). While the small lymphocytes showed aberrant expression of CD5 (C, x 20) and CD23 (D, x 20), the large lymphocytes were negative for CD5 and CD23 but positive for BCL6 (E, x 20) with a high proliferative rate by ki-67 (F x 20). FISH analysis with break-apart probes demonstrated MYC gene rearrangement (G, arrows indicate separation of 5'MYC and 3'MYC) and BCL6 gene rearrangement (H, arrows indicate separation of 3'BCL6 and 5'BCL6), which confirmed the diagnosis of "double-hit" large cell lymphoma.
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CT-guided core biopsy of the pelvic mass showed a diffusely infiltrating large atypical cells (yellow arrow) with intermixed clusters of small lymphocytes (black arrow) (Figure 3A). Immunohistochemical studies showed both small and large lymphocytes were strongly positive for CD20 (Figure 3B). While the small lymphocytes showed aberrant expression of CD5 (Figure 3C) and CD23 (Figure 3D), the large lymphocytes were negative for CD5 and CD23 but positive for BCL6 (Figure 3E) with a high proliferative rate by ki-67 (Figure 3F). FISH analysis with break-apart probes demonstrated MYC gene rearrangement (Figure 3G), arrows indicate separation of 5'MYC and 3'MYC) and BCL6 gene rearrangement (Figure 3H), arrows indicate separation of 3'BCL6 and 5'BCL6), which confirmed the diagnosis of "double-hit" large cell lymphoma.