Low-grade B-cell lymphoma and concomitant extensive sarcoidlike granulomas: a case report and review of the literature

Classic Hodgkin lymphoma with marked granulomatous reaction: A clinicopathologic study of 20 cases

Granulomatous reactions can be associated with various types of lymphoma, most commonly classic Hodgkin lymphoma (CHL). In some cases, the granulomatous reaction is extensive, obscuring the presence of neoplastic cells and potentially leading to delayed diagnosis and treatment. It is unknown if this subgroup of CHL has any unique clinicopathologic features. Here, we assessed the clinical and pathological features of 20 cases of CHL with a marked granulomatous reaction, defined in this study as granulomas representing ≥50% of the total cellularity/space of the specimen. This cohort of patients showed a male predominance (M:F ratio = 1.9:1) and 75% of patients were older than 40 years. Nineteen (95%) patients presented with lymphadenopathy with the neck/supraclavicular areas being most commonly involved (11/19; 58%). Advanced stage (III-IV) disease and B symptoms were present in 69% and 64% of patients, respectively. The morphologic features of these neoplasms fit best with mixed cellularity type. The Hodgkin and Reed-Sternberg (HRS) cells were positive for CD30, PAX5 (weak), pSTAT3 (80%), CD15 (70%), PD-L1 (67%), EBV-encoded small RNA (EBER)/LMP1 (50%) and CD20 (42%), and were negative for CD3, CD5, CD45, ALK and pERK. The histiocytes of the granulomas were positive for PD-L1 (67%), pSTAT3 (50%), and were negative for pERK and cyclin D1. Next generation sequencing using a 162-gene panel was negative for mutations in 4 cases. With a median follow-up of 58.9 months (range, 3.4-199.2 months), the median overall survival was 111 months and the 5-year overall survival was 78%. In summary, patients with CHL and a marked granulomatous reaction can present a diagnostic challenge and the pathologist must be alert to the possible presence of CHL to avert potential misdiagnosis. The histiocytes in the granulomas frequently express PD-L1, likely through the activation of the JAK/STAT pathway, suggesting a potential role for PD-1 blockade therapy in these patients.

Granulomatous Sarcoidosis Mimics

Many granulomatous diseases can mimic sarcoidosis histologically and in terms of their clinical features. These mimics include infectious granulomatous diseases, granulomatous reactions to occupational and environmental exposures, granulomatous drug reactions, vasculitides and idiopathic granulomatous conditions. It is important to distinguish sarcoidosis from these mimics, as a misdiagnosis of these diseases may have serious consequences. This manuscript reviews numerous sarcoidosis mimics and describes features of these diseases that may allow them to be differentiated from sarcoidosis. Distinguishing features between sarcoidosis and its mimics requires a careful review of the medical history, symptoms, demographics, radiographic findings, histologic features, and additional laboratory data. Understanding the clinical characteristics of sarcoidosis and its mimics should lead to more accurate diagnoses and treatment of granulomatous disorders that should improve the care of these patients. As the diagnostic criteria of sarcoidosis are not standardized, it is possible that some of these sarcoidosis mimics may represent varied clinical presentations of sarcoidosis itself.

Diffuse Large B-Cell Lymphoma With a Background of Extensive Granulomatous Inflammation: A Potential Pitfall for Misdiagnosis

Granulomatous inflammation has been reported to be associated with Hodgkin and non-Hodgkin lymphomas. Here, we report a case of recurrent diffuse large B-cell lymphoma (DLBCL) with extensive granulomatous inflammation that was initially misdiagnosed as granulomatous lymphadenitis. In 2019, a 75-year-old Caucasian male presented to our hospital with an enlarged right supraclavicular lymph node. He had a medical history of prostate cancer (in 2004), DLBCL (initially diagnosed in 2009), and rectal adenocarcinoma (in 2017), all of which responded well to treatment. In 2018, the patient had experienced right axillary adenopathy, weight loss, and intermittent night sweats. An excisional biopsy of a right axillary lymph node, performed at another institution, was diagnosed as granulomatous lymphadenitis. In 2019, at our hospital, an excisional biopsy of a right supraclavicular lymph node showed DLBCL in a background of granulomatous inflammation. A review of the prior right axillary lymph node biopsy also showed DLBCL with a background of extensive granulomatous inflammation. Chemotherapy was initiated and the patient’s follow-up showed a good response. We report this case to raise awareness that granulomatous inflammation may obscure the diagnosis of some neoplasms, such as DLBCL, which are less commonly known to have granulomatous inflammation. This may result in delayed treatment and may ultimately affect outcomes.

Coexisting sarcoidosis and occult mantle cell lymphoma

Sarcoidosis and lymphoma are two separate entities that need to be considered in the differential diagnosis of lymphadenopathy. Rarely these two diseases may coexist, in which case there may arise a diagnostic challenge, especially when the available sample is limited. We report a case of occult mantle cell lymphoma arising in an individual with a long history of sarcoidosis.

Gastrointestinal tract metastasis of mandibular diffuse large B-cell lymphoma

Not only diffuse large B-cell lymphoma is a malignancy, but also is initially and orally diagnosed in early stages. However, it could be misdiagnosed with other oral pathologies. However yet, early diagnosis is still crucial for the prognosis, morbidity, and mortality in such cases. Additionally, whole-body scanning with positron emission tomography/computed tomography should be performed for diagnosis and treatment process.

Paraneoplastic sarcoid-like reactions and the eye

BACKGROUND

Sarcoid-like reactions have been reported and confirmed by histopathology in patients with malignant disease. This series demonstrates the complex relationship of malignancy and sarcoidosis as pertaining to the eye, which, to the best of our knowledge, has not been previously reported in the literature.

METHODS

Retrospective case study of five patients with sarcoid-like reactions. Patients 1 to 4 represent patients with ocular sarcoid-like reaction and systemic malignant disease. Patient 5 had ocular malignancy and systemic sarcoid-like reaction; workup revealed renal cell cancer. For each patient, other etiologies of nonnecrotizing granulomatous inflammation were excluded.

RESULTS

Sarcoid-like reactions have been described in the literature when nonnecrotizing granulomas occur in association with malignancy and in the absence of multiorgan involvement as seen with systemic sarcoid. In our series, sarcoid-like reactions involved the vitreous in three patients, retina in one patient, and the choroid and lung in one patient. Sarcoid-like reaction preceded the diagnosis of malignancy in two patients, was found concomitantly with malignancy in one patient, and followed malignancy in two patients. Two patients had hematologic malignancy, one patient had endometrial carcinoma, one had renal cell carcinoma, and one patient had both renal cell carcinoma and uveal melanoma. Four patients had findings of nonnecrotizing granulomas confirmed by histopathology.

CONCLUSION

Sarcoid-like reactions can occur in the eye, and ocular malignancies may incite sarcoid-like reaction. Ocular sarcoid-like reactions have paraneoplastic features in that they can occur at a site distant from malignancy and may precede, occur simultaneously with, or follow malignancy.

Immune reconstitution syndrome presenting as probable AIDS-related lymphoma: a case report

We report an unusual case of HIV-related immune reconstitution inflammatory syndrome, presenting as suspected AIDS-related lymphoma. Symptoms, initial investigations including fine-needle biopsy and 18F-FDG PET/CT scan were highly compatible with high grade AIDS-related lymphoma, however subsequently IRIS was diagnosed. We discuss pitfalls in the interpretation of diagnostic results in ARL versus IRIS.

The sarcoid-lymphoma syndrome

Whether a relationship exists between sarcoidosis and lymphoma is controversial. We present 4 patients diagnosed with sarcoidosis either during or after the treatment of lymphoma, review the data surrounding the entity known as "sarcoid-lymphoma syndrome" and discuss the diagnostic pitfalls it can present. As both entities are fluorine-18 fluorodeoxyglucose avid, histologic verification and clinical acumen are needed to avoid misdiagnosis before initiating therapy.

A case with coincidental diagnosis of primary central nervous system lymphoma and lymph node sarcoidosis

Primary central nervous system lymphoma (PCNSL) is rare. Clinical and histological differential diagnosis of systemic lymphoma and sarcoidosis continues to be a challenge. The first case report in the German and English literature of PCNSL and synchronous sarcoidosis is presented. Synchronous mediastinal lymphadenopathy suggestive of non-Hodgkin's lymphoma (NHL) or sarcoidosis was noted. Both conditions require alternative therapeutic and prognostic considerations to PCNSL. A regime of intrathecal and adjuvant systemic chemotherapy led to transient clinical improvement prior to the patient's demise through overwhelming sepsis and multiorgan failure. Post mortem findings confirmed synchronous PCNSL with mediastinal lymph node sarcoidosis.

Splenic micronodular T-cell/histiocyte-rich large B-cell lymphoma: effect of prior corticosteroid therapy

We report on three patients who were treated with corticosteroids only prior to the diagnosis of splenic lymphoma. Corticosteroids were administered for different conditions, at different doses, and for various periods of time. The primary diagnosis was splenic micronodular T-cell/histiocyte-rich large B-cell lymphoma in the three cases, and it was reached with variable difficulty. We suggest that the corticosteroid treatment was one of the causes for the complications in reaching a diagnosis. The morphologic appearance of the microscopic splenic nodules was the most variable feature and may possibly reflect the dose and duration of the corticosteroid therapy. However, the histopathologic changes are probably not related with Epstein-Barr virus-induced immunosuppression.

Tissue is the issue-sarcoidosis following ABVD chemotherapy for Hodgkin's lymphoma: a case report

Thirty two year old Caucasian female presented 2 months post partum with fevers, cough and shortness of breath. CT scan of the chest to rule out pulmonary embolism revealed mediastinal lymphadenopathy. Biopsy of the nodes revealed classic Hodgkin's lymphoma and she received ABVD chemotherapy. She was in remission as confirmed by a PET/CT scan. Five months later she had another PET/CT scan which showed areas of hypermetabolism indicating a possible relapse. Biopsy revealed sarcoidosis. She received steroids and 18 months later remained in clinical remission. This rare case of sarcoid following classic Hodgkin's lymphoma illustrates that clinical presentation, physical exam, lab investigations and even PET/CT scans may not be able to discriminate between Hodgkin's lymphoma and sarcoidosis. Tissue biopsy and pathological diagnosis remain the gold standard.

Sarcoidosis and malignancy

Malignancy in patients with sarcoidosis occurs in 3 settings. The first setting relates to patients with hematologic malignancies. It includes the sarcoidosis-lymphoma syndrome, which refers to the development of lymphoma at least 1 to 2 years after the diagnosis of sarcoidosis. It also includes patients with sarcoidosis who develop other hematologic malignancies. In addition, this subset of individuals includes patients with cancer and hematologic malignancies who subsequently develop sarcoidosis. The second setting consists of patients with sarcoidosis who develop solid tumors and oncologic patients in whom sarcoidosis subsequently appears; in addition to melanoma and nonmelanoma skin cancer, the neoplasms most commonly associated involve the cervix, liver, lung, testicles, and uterus. The third setting of malignancy-related sarcoidosis occurs when sarcoidosis presents as a paraneoplastic syndrome for the associated cancer, specifically when the discovery of cancer is concurrent with or within 1 year of the diagnosis of sarcoidosis or vis-a-vis. Antineoplastic treatment of either the hematologic malignancy or the solid tumor has also been observed to either induce the initial onset or flare the activity of sarcoidosis. Malignancy can also be associated with the occurrence of sarcoid reactions that typically are restricted to the regional lymph nodes or the visceral organ of tumor origin; rarely, the sarcoid reaction can also be observed in the skin or is only limited to the skin.

Case of keratosis lichenoides chronica with atypical sarcoidal granulomatous inflammation

Keratosis lichenoides chronica (KLC) is a rare chronic disease characterized by violaceous, papular and nodular lesions typically arranged in a linear and reticulate pattern. The etiology of KLC is unknown, but it may be associated with internal diseases such as hypothyroidism, glomerulonephritis and lymphoproliferative disorders. Herein, we describe the case of 44-year-old male patient with characteristic lesions of KLC on the trunk and extremities, present for 12 years. The clinical diagnosis was proven by histopathological examination on several occasions. In the years following the diagnosis of KLC, he developed bilateral hilar and multiple mediastinal, cervical and inguinal lymphadenopathies and hepatosplenomegaly. In 2000, diffuse interstitial and then reticulonodular pulmonary infiltrates associated with fever, weight loss, malaise and subcutaneous nodules developed. Biopsies taken from peripheral and mediastinal lymph nodes, pulmonary parenchyma, pleural tissue, bone marrow and skin showed non-necrotizing granulomas, indicating a sarcoidal granulomatous reaction. Characteristic histopathological findings and the absence of atypical cells, clonality and a high proliferative index excluded lymphomas. Furthermore, detailed tests showed no evidence of an infectious granulomatous disease. As far as we know, this is the first reported case of KLC associated with a sarcoidal granulomatous reaction.

Orbital Lymphoma With Concomitant Sarcoid-Like Granulomas

A 41-year-old man presented with chronic eyelid swelling, conjunctival injection, and decreased ocular motility in all gaze directions. MRI showed bilateral enlarged extraocular muscles, including the tendons. Laboratory tests revealed elevated levels of angiotensin-converting enzyme. An orbital biopsy showed collections of monotonous small lymphocytes, and granulomatous inflammation that included multinucleated giant cells, predominantly Langhans type. Flow cytometric analysis of tissue demonstrated a light chain-restricted clonal population of B cells, a finding that confirmed the morphologic impression of lymphoma. This case demonstrates that elevated angiotensin-converting enzyme and granulomatous inflammation can occur in lymphoma. Careful histopathologic examination and flow cytometric analysis are essential to avoid an erroneous diagnosis that could lead to inappropriate management.

Granulomatous reactions cause symptoms or clinically imitate treatment resistance in small lymphocytic lymphoma/chronic lymphocytic leukaemia more frequently than in other non-Hodgkin lymphomas

AIMS

The electronic database of the institute of pathology, Medical University of Innsbruck, was reviewed and patient histories studied to analyse systematically the coincidence of granulomatous reactions and lymphomas in a large patient collective, and to find distinct clinicopathological correlations. Five cases of small lymphocytic lymphoma/chronic lymphocytic leukaemia (CLL) associated with granulomatous reactions in lymph nodes and bone marrow were identified, all clinically associated with signs of progressive disease.

METHODS

Cases were acquired by reviewing an electronic database comprising approximately 715,000 patients diagnosed between 1993 and 2003. Histochemical, immunohistochemical, and molecular techniques were used to verify diagnosis and associated infectious diseases. Clinical data were obtained from reviewing the charts.

RESULTS

Of 2044 bone marrow and 411 lymph node non-Hodgkin lymphoma biopsy samples, CLL was most frequently associated with bone marrow (two cases) and lymph node granulomas (three cases). These granulomas were mostly composed of epithelioid cells, with or without giant cells, and in all but one case did not show necrosis. All patients with CLL had clinical symptoms primarily caused by the granulomatous disease: two suffered from acid fast bacilli infections (Mycobacterium tuberculosis and mycobacteria other than tuberculosis) and three presented with clinical manifestations of sarcoidosis (the reason a diagnostic biopsy was performed).

CONCLUSIONS

Granulomatous reactions in patients with CLL might obscure diagnosis and imitate disease progression and Richter's transformation. Careful histological examination, exclusion of infectious agents, and a detailed clinical history are essential for correct diagnosis.

Sarcoidosis and immunoglobulin lambda II light-chain amyloidosis diagnosed after orthotopic heart transplantation: a case report and review of the literature

Cardiac involvement by sarcoidosis and concomitant deposition of AL amyloid is an uncommon association. We describe the case of a 53-year-old African-American man with a 7-year history of dilated nonischemic cardiomyopathy and severe cardiac failure who underwent orthotopic heart transplantation. His prior cardiac biopsies had only mild myocyte hypertrophy and minimal interstitial fibrosis. After surgery, numerous sarcoid granulomas and amyloid deposition were identified in the native heart. Six days after the transplant the patient died due to aspiration bronchopneumonia and acute renal failure. At autopsy, both sarcoidosis and immunoglobulin (Ig) lambda light-chain amyloidosis were present in the native atria, lungs, thyroid, liver, spleen, and kidneys. Sarcoid granulomas alone were present in the parathyroids, lymph nodes, and bone marrow. Amyloid deposition alone was present in the aorta, stomach, large bowel, and urinary bladder. There was no evidence of plasma cell dyscrasia, or underlying gammopathy. This unusual association was described in only two other cases in the medical literature. However, this is the first case of sarcoidosis and AL amyloidosis with successful sequencing and identification of Ig lambda light-chain amyloid, and in which there was no evidence of plasma cell dyscrasia.

Florid Granulomatous Reaction in Epstein-Barr Virus-positive Nonendemic Burkitt Lymphomas

Epithelioid cell granulomas have been reported in association with a wide range of neoplasms including malignant lymphomas. In lymphoma, this refers mainly to Hodgkin disease and T-cell-derived non-Hodgkin lymphomas where a granulomatous reaction is probably evoked by aberrant cytokine production in the tumor cells or other cells composing the tumor background. Here we report on four cases of sporadic Burkitt lymphoma with unusual florid granulomatous reaction. In all samples, the tumor cells were admixed with numerous epithelioid cells that formed clusters and granulomatous lesions. No microorganisms could be detected at the tissue level, and there were no clinical or laboratory indications of an underlying immunodeficiency. The lymphomas harbored a specific morphology and immunophenotype of Burkitt lymphoma, and the presence of translocation breakpoint in MYC gene was confirmed by interphase fluorescence in situ hybridization. In all four patients, the lymphoma was associated with Epstein-Barr virus infection, detected by EBER in situ hybridization and the latency I phenotype as defined by lack of expression of LMP1. All four patients were treated with polychemotherapy, achieved a complete remission, and are alive without evidence of disease. We draw attention to this unusual phenomenon as it caused difficulties in interpretation and delayed diagnosis and hypothesize on the possible role of Epstein-Barr virus products.