Cytologic diagnosis of peripheral T-cell lymphoma manifesting as ascites. A case report

BACKGROUND

Patients with malignant lymphoma seldom present with effusions without a known history of malignancy. Because of this, initial diagnosis of malignant lymphoma by effusion cytology is uncommon, with few reported cases.

CASE

A 75-year-old male presented with fatigue, decreased appetite and progressively increasing abdominal girth over five weeks. Cytologic examination of ascitic fluid obtained by paracentesis revealed non-Hodgkin's lymphoma with a T-cell phenotype, confirmed by immunophenotypic and molecular studies. Approximately one week later, histologic examination of liver and bone marrow revealed involvement by lymphoma, demonstrating immunophenotypic and molecular profiles identical to those obtained from neoplastic lymphocytes recovered from the ascites fluid.

CONCLUSION

This case demonstrates a rare presentation of peripheral T-cell lymphoma, clinically manifesting as ascites. In cases such as ours, where the effusion consists predominantly of small to intermediate-sized lymphocytes, distinguishing lymphoma from reactive lymphocytosis may be difficult. This case not only demonstrates the value of effusion cytology for lymphoma diagnosis but also illustrates how the use of various immunophenotypic and molecular techniques may assist the pathologist in properly diagnosing these difficult cases.

Cytomegalovirus-infected cells in routinely prepared peripheral blood films of immunosuppressed patients

We describe 4 patients identified over 5 years with large atypical cells on the feathered edge of routinely prepared peripheral blood films. Films were reviewed either as part of a blood film consultation or a bone marrow examination. The cells were 50 to 60 microns in diameter, with granular eosinophilic cytoplasmic inclusions and eccentric enlarged nuclei. Additional studies including buffy coat preparations and immunohistochemistry revealed that these were circulating cytomegalovirus (CMV)-infected cells, most likely of endothelial origin. All patients were immunocompromised (3 had HIV infection, and 1 was an organ transplant recipient) and had clinical evidence of CMV infection. The unique appearance of these cells at Wright-Giemsa staining, and their possible misidentification as malignant cells or other cells, highlights the need for pathologists to be aware of their morphologic features and possible clinical implication.

Follow-up of atypical glandular cells in cervical-endocervical smears

Atypical glandular cells of undetermined significance (AGUS) is a diagnostic category of the Bethesda system encompassing glandular-type cells that show either endometrial or endocervical differentiation and display greater atypia than expected for a reactive process but do not meet the criteria for invasive adenocarcinoma. We investigated AGUS in a follow-up study of cervical-endocervical smears with either histology or repeat cytology follow-up. From the cytology files at Northwestern Memorial Hospital over a 4-year period, 136 cervical-endocervical smears were diagnosed with AGUS, which were further subdivided into atypical glandular cells, unqualified (AGC-U); atypical glandular cells, favor reactive (AGC-FR); or atypical glandular cells, favor neoplasia (AGC-FN). Of 96 cases with either histologic or cytologic (cervical-endocervical smear) follow-up, 39 cases of AGC-U had a variety of diagnoses on follow-up, with mostly benign entities in 72% and squamous intraepithelial lesions in 28%. Follow-up of the 36 cases of AGC-FR also demonstrated mostly benign entities (82%) and five cases of squamous intraepithelial lesions. The largest number of premalignant and malignant diagnoses (48%) was found during follow-up of patients with an initial diagnosis of AGC-FN, including the only two cases of adenocarcinoma in situ in our study. In conclusion, our study confirms that AGUS encompasses a wide spectrum of diagnoses, most of which prove to be benign. Subclassification of these cases into "favor reactive" and "favor neoplasia" was found to be helpful in predicting the follow-up status of these patients. However, the small but distinctive percentage of preneoplastic and neoplastic diagnoses seen on follow-up warrant further diagnostic procedures and/or close monitoring in patients with this diagnosis.