Hematopathology Case 01

78-Year Old Male with Supraclavicular Lymphadenopathy: A Diagnostic Pitfall

by Archana M. Agarwal, MD, Assistant Professor of Pathology, University of Utah School of Medicine
Medical Director, ARUP Laboratories
Nikhil A. Sangle, MD and Barnali Deka, MD.
Editor: Mohamed E. Salama, MD, Associate Professor (Clinical) of Pathology, University of Utah School of Medicine
Medical Director, ARUP Laboratories

A 78- year old male presented with a 2.0cm diameter enlarged left supraclavicular lymph node. The patient had a previous diagnosis of chronic lymphocytic leukemia (CLL). The patient had been recently feeling worse and a left supraclavicular lymph node biopsy was performed to rule out either transformation of the CLL to a large cell lymphoma or some other disease process.

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Pathology Findings:

  • Hematoxylin & eosin stained sections of the left supraclavicular lymph node showed a complete effacement of the architecture by atypical follicles and interfollicular expansion.
  • The follicles lacked well-defined mantle zones as well as polarity.
  • They were variably sized and were composed predominantly of small-cleaved cells with irregular nuclear contours, clumped chromatin and inconspicuous nucleoli.
  • Interfollicular areas showed proliferation of predominantly small lymphocytes with oval to round nuclei, and clumped chromatin (fig. 1) (fig. 2).
  • The lymphoproliferative process was also seen outside the capsule.

Immunophenotype Findings:

  • Immunohistochemical stains for CD3, CD20, CD5, BCL-6, CD10, MIB-1 and BCL-2 were performed with adequately reactive controls.
  • CD20 stain highlighted the follicles as well as the interfollicular areas.
  • However, the intensity of the CD20 stain was much weaker in the atypical cells of the interfollicular areas (fig. 3).
  • The cells of the interfollicular areas also showed co-expression of CD5 (fig. 4).
  • BCL-2 stain was strongly positive on the majority of the follicles and weakly positive on the cells of the interfollicular areas (fig. 5).
  • CD10 stain highlighted the cells of the follicles (fig. 6).
  • Multiple attempts to perform FISH studies to ascertain relationship between these two lymphomas failed due to technical reasons.
  • The case was diagnosed as a composite follicular lymphoma and chronic lymphocytic lymphoma.

Final Diagnosis & Discussion

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