Extraoral plasmablastic lymphoma detected using ascitic fluid cytology and flow cytometry: a case report with a review of the literature

BACKGROUND

Plasmablastic lymphoma (PL) is a relatively new category of lymphoma, which has been considered to be found predominantly in the oral cavity and has a strong association with HIV.

CASE

We report a case of extraoral/mesenteric PL detected using cytological examination of ascitic fluid assisted by flow cytometric (FC) analysis. The cells were positive for CD38, CD138, CD10, CD45 and CD56 and negative for CD3, CD19, CD20 and CD79a, with cytoplasmic lambda light-chain restriction. We also reviewed 67 cases of extraoral PL from the available literature and found them to be less often associated with HIV (than oral PL), occurring mostly in males aged 30-60 years, with the most common extraoral site being the anorectal region.

CONCLUSION

A high index of suspicion at the level of the cytopathologist is imperative for identifying lymphoma cells in a body fluid. A rare entity like PL can also be diagnosed on cytology assisted by ancillary techniques (like FC), without the need for a biopsy. We also suggest that the minimum panel to diagnose PLs should include CD138, MUM-1, Ki-67, ALK-1, CD3, immunoglobulin light-chains, CD20 and PAX5.

Plasmablastic lymphoma in the orbit: case report

Plasmablastic lymphoma (PBL) is a rare entity most commonly identified in the oral cavity of immunodeficient patients. The immunophenotype of this condition shows a poor expression for B-cell markers but, in contrast, a strong reactivity for well-differentiated plasma cells markers, such as CD138, CD38, and epithelial membrane antigens. PBL survival is limited due to its highly aggressive local and metastatic behavior and poor response to treatment. Although it can involve different organs, there have been only a few cases involving the ocular adnexa. We describe a case of atypical rapidly progressive pre-septal brawny induration affecting the right orbit in a patient with HIV-related lymphoma.

Sepsisähnliches Krankheitsbild bei Immunsuppression nach früherem Mallorcaurlaub

In immunosuppressed patients, a high rate of complications due to opportunistic infection is known. We report the case of a 36 year old patient with ulcerative colitis and a septic complication with ongoing pancytopenia. Due to colonic perforation, colectomy had to be performed. Despite this intervention, the septic constellation persisted. The pancytopenia in peripheral blood counts also persisted with the necessity of repetitive transfusions. A bone marrow biopsy showed an infiltration with Leishmania bodies in macrophages. Tissue culture allowed for typing of the parasites as belonging to the L. donovani/infantum complex, DNA sequencing confirmed infection with L. infantum. This infection must have been contracted during a vacation on Mallorca about 1.5 years earlier. Administration of liposomal amphotericin B cured the patient. Surprisingly, histological examination of the resected colon reveiled the presence of an immunoblastic B-cell lymphoma. In this case, immunosuppression was a prerequisite for the manifestation of leishmaniosis.

Large Cleaved and Immunoblastic Lymphoma May Represent Two Distinct Clinicopathologic Entities Within the Group of Diffuse Large B-Cell Lymphomas

Purpose

The reliability of immunohistochemistry for subdividing diffuse large B-cell lymphomas (DLBCL) into germinal center B-cell-like (GCB) and non-GCB prognostic subgroups is debated. In this study we evaluated the prognostic significance of such subgrouping on a series of 153 DLBCL patients. Furthermore, we investigated whether both subgroups could comprise clinicopathologic entities recognized by their morphology and characterized by a distinct phenotype, specific genetic abnormalities, and clinical characteristics.

Patients and Methods

All samples from patients were reviewed and morphologically subdivided into large cleaved, immunoblastic, and not otherwise specified DLBCL. GCB and non-GCB immunohistochemical profiles were established. The presence of chromosomal translocations involving BCL2, BCL6, and MYC and/or rearrangements of these genes was investigated.

Results

Subdividing DLBCL with either a GCB or non-GCB immunophenotypic profile was not of prognostic significance. Nevertheless, CD10 expression was a predictor of favorable outcome, whereas high bcl-2 expression and BCL6 rearrangement were adverse predictors of disease-free survival. Interestingly, large cleaved DLBCL was clearly associated with a GCB immunophenotypic profile, CD10 expression, BCL2 rearrangement, age younger than 60 years, and low to low/intermediate International Prognostic Index risk, but was not of prognostic significance. In contrast, immunoblastic morphology was associated with a non-GCB profile and was a significant predictor of unfavorable DFS.

Conclusion

Subdividing DLBCL into subgroups based on their immunohistochemical profile was not of prognostic significance. Nevertheless, it allowed the additional characterization of two lymphoma subgroups previously recognized in the Working Formulation. Both correspond to two distinct clinicopathologic entities within the DLBCL.

Immunoblastic large B-cell lymphoma of the peripancreatic head region: MR findings

We report the magnetic resonance (MR) appearance of a large B-cell lymphoma in the peripancreatic head region, in a 38-year-old male who presented with a 1-month history of pruritus and jaundice. Routine laboratory examination at presentation revealed an elevated bilirubin. The tumor was a large, solitary well-defined mass with no evidence of necrosis, which showed mild diffuse heterogeneous enhancement. The tumor was closely applied to the lateral margin of the head of the pancreas. The constellation of MR findings was interpreted as consistent with the correct eventual diagnosis of lymphoma.

[Is Dacron carcinogenic? Apropos of a case and review of the literature]

Primary malignant cardiac tumours are extremely rare. The authors report a case of primary cardiac lymphoma nine years after implantation of a double leaflet mitral valve prosthesis. Malignant lymphoma is a haematological form of sarcoma. Exceptionally rare, it is a tumour of the immune system occurring principally in immuno-depressed patients. It typically presents as a nodular or diffuse myocardial infiltrate explaining its clinical expression as cardiac failure and atrioventricular block. In view of the usual degree of infiltration, surgery is rarely possible. Survival after "pure" medical therapy (chemotherapy alone or associated with radiotherapy) is 6 to 8 months after diagnosis. Dacron has been implicated in the pathogenesis of primary cardiac sarcoma. Oppenheimer demonstrated experimental induction of sarcoma in the rat by subcutaneous implantation of polymers. In conclusion, although primary cardiac lymphoma is a rare condition, it should be considered, as with thrombosis, a possible differential diagnosis of acute dysfunction of cardiac valvular prostheses.

Primary lacrimal sac B-cell immunoblastic lymphoma simulating an acute dacryocystitis

The case of a 72-year-old woman with diffuse large B-cell lymphoma of the lacrimal sac is reported. The patient was evaluated for the first time in our department for tearing of the right eye. One month later, a slightly aching mass appeared over the right lacrimal sac. An acute infectious etiology was suspected and antibiotic therapy was given. When she finally presented with a rapidly growing lesion, she underwent echography and computed tomography followed by incisional biopsy. Results of histopathologic and immunohistochemical evaluation showed a primary, diffuse, large B-cell non-Hodgkin lymphoma of the lacrimal sac. This case demonstrates how difficult the clinical diagnosis of tumors of the lacrimal sac may be in the early stages. The clinical signs, usually aspecific, may be misleading and the diagnosis delayed.

Clinicopathologic features of ileocolonic malignant lymphoma: analysis according to colonoscopic classification

BACKGROUND

The aims of this study were to classify primary ileocolonic lymphomas according to colonoscopic findings and to determine the clinicopathologic relationship according to classes.

METHODS

Thirty-two patients (22 men, 10 women; age range 29 to 75 years) with primary malignant lymphoma of the terminal ileum and/or colorectum were studied. The clinicopathologic features were evaluated according to colonoscopic findings.

RESULTS

Thirty-six lesions in 32 patients were endoscopically classified as follows: fungating (14, 39%), ulcerofungating (11, 31%), infiltrative (5, 14%), ulceroinfiltrative (4, 11%), and ulcerative (2, 6%). Location of the lesions was as follows: terminal ileum, 15 (42%); colorectum, 14 (39%); both regions, 7 (19%). The most common histopathologic types were diffuse large cell (22, 69%) and large cell immunoblastic (5, 16%). There was no relationship between the endoscopic findings and histologic types. In 9 patients (28%), the clinical manifestation was intussusception, and all were found endoscopically to have the fungating type lesion.

CONCLUSIONS

Primary ileocolonic lymphomas can be classified endoscopically into fungating, ulcerative, infiltrative, ulcerofungating, and ulceroinfiltrative types. Among these, fungating and ulcerofungating are the most frequent. Intussusception is a common clinical finding in ileocolonic lymphomas, occurring mainly in patients with the fungating type of lesion.

A man with hereditary exostoses and high-grade non-Hodgkin's lymphoma of the bone

Multiple cartilaginous exostoses (MCE) is an autosomal dominant disorder that can lead to malignant transformation from exostoses to a secondary chondrosarcoma. We present a case report of a 52-year-old man with MCE who had a palpable mass at the left shoulder. At the site of the left proximal humerus, a cartilaginous exostosis was localized, suggesting that the tumor developed by a malignant transformation of an exostosis into a secondary chondrosarcoma. Interestingly, a biopsy showed a diffuse large B-cell lymphoma with Burkitt-like features. To our knowledge, the association of high-grade lymphoma and hereditary exostoses has not been described previously. This case demonstrates that a malignant tumor at the location of a cartilaginous exostosis is not necessarily a chondrosarcoma and that a biopsy is an essential part of the diagnostic work-up.

Primary malignant lymphoma of the ovary: an unusual presentation of a rare disease

Because the outcome of patients with primary ovarian non-Hodgkin's lymphoma (NHL) is controversial, we present the incidental finding of a primary malignant lymphoma of the ovary in a 50-year-old patient. Three and a half years following ablative surgery and adjuvant chemotherapy, the patient is alive and disease free. Ovarian lymphoma is a disease of reportedly poor prognosis. However, many previously reported cases of ovarian lymphoma actually represented ovarian involvement by a more diffuse lymphomatous process. If stringent criteria are used for case selection, true primary ovarian lymphoma is a very rare disease and usually carries a favorable prognosis.

Perianal lymphoma in a heterosexual and nonimmunocompromised patient: report of a case and review of the literature

PURPOSE

This study was conducted to report a rare case of anorectal pathology.

METHODS

We report a case of perianal lymphoma in a nonimmunocompromised, heterosexual patient and review the literature.

RESULTS

A 67-year-old white male was found to have an ulcerated posterior anal mass. Biopsy revealed large cell lymphoma, B cell type, immunoblastic. There was no disseminated disease. The patient denied any homosexual activity and was HIV negative. There was complete resolution with chemotherapy (cyclophosphamide, doxorubicin, vincristine, and prednisone), and he remained disease free for six years.

CONCLUSIONS

Rare anorectal pathology may mimic common conditions. Biopsies should be taken to rule out malignancy.

A patient with bilateral primary adrenal lymphoma, presenting with fever of unknown origin and achieving long-term disease-free survival after resection and chemotherapy

Primary adrenal lymphoma is extremely rare. We describe a 64-year-old female patient who presented with fever of unknown origin. Imaging studies demonstrated bilateral bulky adrenal masses. She underwent bilateral adrenalectomy and the pathological diagnosis was large cell immunoblastic (B-cell) lymphoma. She received adjuvant combination chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisolone in the following 6 months. She has been relapse free for 52 months. To the best of our knowledge, this case has the longest disease-free survival among those reported. The present case indicated that primary adrenal lymphoma should be included in the differential diagnosis of fever of unknown origin and/or suprarenal mass. Chemotherapy following surgical resection may be considered the treatment of choice.

Anaplastic large-cell lymphoma (Ki-1 lymphoma) and diffuse large-cell immunoblastic lymphoma: two diagnostic problem cases

Electron microscopy can be used to establish diagnoses in some otherwise difficult cases of neoplasia, but it is not generally regarded as important in the diagnosis of lymphoma. However, in some cases of anaplastic tumors not initially recognized as lymphomas, electron microscopy can prove quite valuable. Two cases are reported in which lymphoma was not suspected on the basis of the histologic findings, but was diagnosed by electron microscopy. Case 1 involved a 60-year-old woman who presented with a retroperitoneal mass that was located primarily in the body of the psoas muscle. Nuclear pockets were seen with electron microscopy. Ultimately she was diagnosed with anaplastic large-cell lymphoma (Ki-1 lymphoma). Case 2 involved a 43-year-old male with retroperitoneal lymphadenopathy, renal failure, polyclonal gammopathy, and a febrile illness. Signet-ring cells without junctions were identified with electron microscopy. Immunoperoxidase stains confirmed diffuse large-cell immunoblastic lymphoma.

AIDS-related lymphomas with neurologic manifestations

Images

[Perirenal immunoblastic lymphoma. Description of a case]

The primary perirenal localization of non-Hodgkin lymphomas is rare and normal methods of image diagnosis do not enable a reliable preoperative diagnosis. In the majority of cases renal function is not affected and this pathology is often presented as an occasional finding. The pathologies included in the differential diagnosis are renal neoplasias, abscess and inflammatory processes in a perirenal site. Echotomography shows the lesion as an hypoanechoic zone surrounding the kidney. Computed tomography show it as isodense with the renal parenchyma. Histological tests together with immunohistochemical tests identified a malignant large B cell immunoblastic-type lymphoma in the case described here, with plasmoblastic-plasmocytic differentiation and high malignancy according to the Working Formulation. The pathogenesis of this rare localisation is controversial. We maintain that lymphomatous proliferation may be triggered off by lymphatic follicles present in the perirenal space. The concomitant presence of other clinical signs, such as splenomegalia and adenopathies, may contribute to the diagnosis. On the contrary, monolateral involvement in the absence of other signs, as in this case, raises considerable problems of differential diagnosis. Perirenal lymphoma must therefore always be borne in mind in the diagnosis of renal or perirenal masses.

[Immunoblastic highly malignant lymphoma of the uterine cervix]

Report on a case of a highly malignant solitary lymphoma of the cervix uteri in a 51-year-old patient. The only noticeable finding leading to the diagnosis was the pathological result of the routine cervical smear. Solitary malignant lymphomas of the cervix must be seen as systemic diseases. They should therefore be treated by local surgical intervention and consecutive systemical chemotherapy in an interdisciplinary conception.

Combined chemotherapy and radiotherapy in diffuse large cell immunoblastic lymphoma: a phase II study of CHOP/bleomycin/methotrexate alternating with ifosfamide/methotrexate/etoposide

The clinical outcome of 23 patients with high grade diffuse large cell immunoblastic lymphoma (Working Formulation, category H) treated by an intensive shortened schedule regimen of chemotherapy is described. Alternating cycles of cyclophosphamide, doxorubicin, vincristine, bleomycin and prednisolone, and ifosfamide, etoposide and methotrexate were given over an 18-week (range 16.0-20.8) period. External beam radiotherapy was administered as consolidation therapy to sites of original bulky disease in 17 patients. Treatment was well tolerated, though there were two toxic deaths. A 90% response rate was obtained. Sixteen of 18 patients followed for a minimum of 36 months are alive and in complete remission, representing a disease free survival of 69.5%; two further patients are alive following autologous bone marrow transplant. The 3-year disease free survival was 73% (+/- 9%) and the overall 3-year survival 78% (+/- 9%).

Endobronchial HIV associated lymphoma

A 27 year old HIV infected man presented with two days of haemoptysis. Flexible bronchoscopy revealed a large carinal mass partially obstructing the left and right main stem bronchi. Rigid bronchoscopy was required to make the diagnosis of large cell immunoblastic lymphoma.

Childhood polymyositis as a paraneoplastic phenomenon

Childhood polymyositis and dermatomyositis are rare conditions that are not generally associated with malignancy even though an association between adult-onset and malignancy has been reported. A child is presented with typical polymyositis in whom an immunoblastic sarcoma subsequently became manifest; the literature also is reviewed concerning the association between malignancy and these childhood conditions.

Lymph node blast crisis in chronic myeloid leukemia mimicking T-immunoblastic lymphoma

BACKGROUND

Chronic myeloid leukemia arises from a somatic mutation in a pluripotent stem cell. It generally terminates with a blastic crisis (BC). One third of BC are lymphoid, and most have a pre-B phenotype. Few cases of T-lymphoid BC have been reported. Here we describe a lymph node blast crisis mimicking T-immunoblastic lymphoma.

METHODS

Bone marrow and lymph nodes were histologically examined by standard methods and by an immunoperoxidase technique. Cytogenetic studies were also performed on lymph node and blood cells. Analysis of T-cell receptor genes and BCR rearrangements were performed on DNA extracted from both frozen bone marrow and lymph-node cells.

RESULTS

Lymph-node histology showed an infiltration by large lymphoid blasts, consistent with a diagnosis of immunoblastic lymphoma. Blast cells were CD2, CD7, TDT positive, and negative for myeloid and mature lymphoid antigens. The Ph1 chromosome was found in both bone marrow and lymph-node cells. BCR rearrangement was found in the DNA from both bone marrow and lymph-node cells. TCR genes were not rearranged.

DISCUSSION

The present study provides strong evidence that the lymph-node blast crisis of CML can assume the morphological appearance of immunoblastic lymphoma and may retain the immunological phenotype and genetic features of early T cells with BCR rearrangements.

[The reactive hemophagocytic syndrome associated with immunoblastic B-cell lymphoma]

The reactive hemophagocytic syndrome is a rare clinical-pathological entity which usually has a benign evolution and which is characterized by the systemic proliferation of mature histiocytes, with a great phagocytosis ability and which occurs in a secondary form in some infections and neoplasias and after the administration of certain drugs. We present a case of reactive hemophagocytic syndrome in a patient presenting a non-Hodgkin lymphoma, of crest malignancy, B immunoblastic and kappa monoclonal, with fatal evolution and in which the diagnosis was obtained after necropsy.

Lymphoma-induced polyradiculopathy in AIDS: two cases

Progressive polyradiculopathy is a rare, well-documented complication of the acquired immunodeficiency syndrome in man. It has been commonly attributed to a cytomegalovirus (CMV) infection. We report two HIV-infected patients with clinical and electrophysiological features of a unique, subacute, progressive polyradiculopathy. Post-mortem examination in case 1 disclosed an infiltration of the leptomeninges, the lumbar spinal cord, and the anterior and posterior roots by a B-cell immunoblastic lymphoma. Immunochemistry for HIV1 and CMV was negative in the peripheral and the central nervous system. Case 2 showed bone-marrow involvement by a Burkitt type lymphoma. Specific chemotherapy was followed by both clinical improvement of the polyradiculopathy and complete remission on a second bone-marrow biopsy. These findings may indicate that a lymphoma must also be considered a possible cause of polyradiculopathy in AIDS.

Malignant angioendotheliomatosis presenting as disseminated intravascular coagulopathy

Disseminated intravascular coagulopathy (DIC) occurred in a patient with hemolytic anemia and anasarca. Skin and muscle biopsy showed intravascular lymphomatosis (malignant angioendotheliomatosis). Combination chemotherapy resulted in resolution of the DIC and anasarca. After an unmaintained 8-month clinical remission, the patient had central nervous system relapse and died. Malignant angioendotheliomatosis is a rare disorder that should be considered among the occult causes of DIC.

[Primary brain lymphoma]

Between 1973 and 1989, 739 patients with non-Hodgkin's lymphoma were referred here for treatment, of whom 10 (1.4%) had primary brain lymphoma (PBL) and 1 had acquired immunodeficiency syndrome (AIDS). There were 7 females and 3 males (mean age 58 years, range 35-77). Duration of symptoms ranged from several days to 3 weeks. The presenting symptoms were secondary to increased intracranial pressure. Computerized tomography (CT) performed in 8 revealed a solitary lesion in 7. Other CT scan features were various degrees of contrast enhancement, edema and midline shift. The most common site was the frontal lobe; infratentorially, the cerebellum was the most frequent site. The diagnosis was established in 8 patients by surgery and in 2 at autopsy. The most common subtype was the diffuse, large cell, immunoblastic lymphoma. 5 patients were irradiated following subtotal excision and 2 had combined radiation therapy and high-dose methotrexate-based chemotherapy; only 1 had no postoperative treatment. All patients treated by radiotherapy alone died within 3-5 months after diagnosis. The 2 who received combined therapy are alive, 15 and 48 months after diagnosis, respectively.

[Idiopathic myelofibrosis associated with an IgM-secreting immunocytoma]

A case of idiopathic myelofibrosis developing in conjunction with IgM secreting immunocytoma is described. The possible pathogenetic implications of the association between myeloproliferative and lymphoproliferative disorders are discussed.

[Incidence of epithelial neoplasms in the head and neck area in non-Hodgkin's lymphomas]

There is an increased risk of malignancy in patients with genetically determined or acquired immunosuppression. The authors report a case of a 70-year-old patient with a lymphoplasmocytic immunocytoma who developed 19 squamous-cell carcinomas (SCC) and nine basal-cell carcinomas (BCC) over a three-year period. This was the reason to review 100 cases of malignant lymphomas for evidence of additional malignancies. Of these patients, 15% had one or more SCC or BCC in the head and neck area. The age range was 59 to 79 years (mean, 71.7 years) and the male:female ratio 11:4. One or more SCC arose in 93% of these patients, 36% developed an additional one or more BCC, and BCC alone occurred in 7%. The usual ratio of BCC:SCC is 10:1; in the authors' patients, by contrast, this ratio was 6:14. In 12 cases, SCC and BCC were located on the skin. The remaining cases of SCC developed in the oral mucosa, the tonsils and the hypopharynx. In 13 cases, low-grade malignant lymphomas were found and in two cases high-grade malignant lymphomas were found. The SCC were clinically aggressive. Thirty-six percent of the patients had recurrent lesions, 43% multiple neoplasms, and 50% metastases. Histologically, the SCC showed moderate to poor differentiation, a high degree of cell polymorphism and mitotic activity, and deep tissue infiltration. There are several explanations for the increased incidence of neoplasms in patients with immunodeficiency disorders. The surveillance function of the immune system may be impaired due to the disease itself or due to the treatment for immunosuppression. Immunosuppressive and cytotoxic agents are potential carcinogens.(ABSTRACT TRUNCATED AT 250 WORDS)