Diagnostic Difficulties of Pure Intrasinusoidal Bone Marrow Infiltration of Non-Hodgkin's Lymphoma: A Report of Eight Cases from India

Diagnosis of intravascular large B cell lymphoma: novel insights into clinicopathological features from 42 patients at a single institution over 20 years

This study aimed to clarify the comprehensive clinical, laboratory, pathological and imaging features of intravascular large B‐cell lymphoma (IVLBCL) using data on 42 IVLBCL patients diagnosed at our hospital over the past 20 years. The majority of patients were diagnosed via random skin biopsy (29/42, 69·0%) followed by bone marrow biopsy alone (8/42, 19·0%). Characteristic features included persistent fever (41/42, 97·6%), decreased performance status (≥2) (100%), hypoxaemia (32/40, 80·0%), impaired consciousness (19/42, 45·2%), hypoalbuminemia (42/42, 100%) and extreme elevation of lactate dehydrogenase and soluble interleukin 2 receptor levels. Brain magnetic resonance imaging showed abnormal findings in 32/37 patients (86·4%). Hyperintense lesion in the pons was a peculiar finding that was unrelated to the neurological deficits. Positron emission tomography‐computed tomography revealed a high incidence of bone marrow (26/34, 76·5%), spleen (19/34, 55·9%) and adrenal gland (9/34, 26·5%) involvement. Neurolymphomatosis was noted in 6 patients during the course of the disease. About 60% of IVLBCL patients in whom in vivo diagnosis was possible survived more than 5 years with combination chemotherapy. Our observations provide additional insight into the diagnosis of IVLBCL and indicate that early disease recognition via random skin biopsy combined with imaging, enables in vivo diagnosis of the disease and improved survival for many patients.

Role of blood and bone marrow examination in the diagnosis of mature lymphoid neoplasms in patients presenting with isolated splenomegaly

OBJECTIVES

Mature lymphoid neoplasms presenting with 'prominent splenomegaly without significant lymphadenopathy' are uncommon and pose unique diagnostic challenges as compared to those associated with lymphadenopathy. Their descriptions in the literature are largely limited to a few case series. We analyzed the spectrum of these lymphomas diagnosed by peripheral blood (PB) and/or bone marrow (BM) examination.

METHODS

Over a period of 6 years, 75 patients were diagnosed with a lymphoma from PB/BM who had presented with predominant splenomegaly. Their clinical and laboratory records including PB and BM morphology; immunophenotyping using multi-parametric flow-cytometry and immunohistochemistry were reviewed. Wherever indicated, an extended panel of immunohistochemistry (IHC) was performed on BM biopsies for accurate sub-classification.

RESULTS AND DISCUSSION

The commonest lymphomas were hairy cell leukemia (HCL) (32%) and splenic marginal zone lymphoma (SMZL) (24%). Others included diffuse large B cell lymphoma (8%), chronic lymphocytic leukemia/small lymphocytic lymphoma (8%), mantle cell lymphoma (2.7%), and follicular lymphoma (1.3%), all of which usually presents with lymphadenopathy. SMZL was the commonest lymphoma among females and those with massive splenomegaly and lymphocytosis; while HCL was commonest in patients with pancytopenia. SMZL commonly presented with lymphocytosis; however, 22% of them also presented with pancytopenia.

CONCLUSION

The high diagnostic efficacy of PB and BM examination using flow-cytometry and immunohistochemistry in confirming and sub-classifying splenic lymphomas suggests that a thorough hematological evaluation should always precede a diagnostic splenectomy. Immunohistochemistry remains the best modality to identify sparse or intra-sinusoidal infiltration on BM biopsy and is particularly useful in patients with fibrotic marrows and pancytopenia.