CASE 1

Explanation:

Review this case before looking at subsequent cases. On low power, note the architecture (compare to the diagram) and identify the following: capsule, subcapsular sinus, lymphoid follicles with germinal centers, interfollicular region, paracortical region, and medullary areas. Although some features of the architecture are subtle, they are distinctly different from the effaced lymph node architecture found with lymphomas.

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CASE 2:

History:

A 64-year-old man has noted lumps in his neck and axillae for approximately one year. These lumps had disappeared 5 months ago and then had recurred. He is otherwise asymptomatic. On physical examination, he has several non-tender, movable, rubbery 1 to 3 cm lymph nodes palpable in both sides of his neck and in his axillae. On abdominal examination, the spleen tip is palpable. A CBC shows WBC count 7700/microliter, Hgb 11.9 g/dL, Hct 36%, MCV 85 fL, and platelet count 207,000/microliter. An axillary lymph node biopsy is performed.

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Questions:

1. On low power, how does the architecture differ from that of the normal lymph node?
2. Under high magnification, how do the lymphocytes in the follicles appear as compared to those in a normal lymph node?
3. What is your diagnosis?
4. What is the molecular biology of this disease and what biotherapy is available to treat it?

CASE 3

History:

A 69-year-old man has noticed several lumps in his neck and axillae that have persisted over the past year. On physical examination, he has a palpable spleen and multiple medium-sized, rubbery, non-tender lymph nodes palpable in both sides of his neck, axillae, and inguinal regions. A CBC shows Hgb 11.1 g/dL, Hct 33.2%, MCV 85 fL, platelet count 109,000/microliter, and WBC count 24,800/microliter with WBC differential count 18 segs, 1 band, 79 lymphs, and 2 monos. His direct Coombs test is positive. A biopsy of an axillary lymph node is performed.

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Questions:

1. What is the pattern of the lymph node observed under low power magnification?
2. Under high power magnification, compare the appearance of the neoplastic cells to the few remaining normal lymphocytes present.
3. What is your diagnosis in this case?

CASE 4

History:

A 61-year-old woman has had bouts of of abdominal pain along with a 3 kg weight loss over the past 2 months. Physical examination reveals no palpable peripheral lymphadenopathy. She has no hepatosplenomegaly. A stool sample is negative for occult blood. A CBC reveals Hgb 13.1 g/dL, Hct 40.0%, MCV 96 fL, platelet count 287,000/microliter, and WBC count 8850/microliter. An abdominal CT scan shows an 8 x 10 cm solid mesenteric mass. A biopsy of the mass is performed.

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Questions:

1. Is this a diffuse or nodular pattern?
2. AT high magnification, compare the neoplastic cells to the few remaining normal lymphocytes present.
3. What is your diagnosis in this case?
4. What special studies could be done with this tissue to arrive at a more definitive diagnosis?

CASE 5

History:

A 27-year-old woman presents to her physician with a month-long history of dull chest pain. She has no dyspnea and reports no hemoptysis. On physical examination, her lungs are clear to auscultation. She has no lymphadenopathy or hepatosplenomegaly. She does have plethora of the head and neck region. A CBC shows Hgb 13.1 g/dL, Hct 39.5%, MCV 91 fL, platelet count 215,000/microliter, and a WBC count of 6350/microliter. Resection of a lesion is performed.

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Questions:

1. What would a chest radiograph reveal?
2. What histologic features are noted at low power?
3. What type of cells are present in the nodules? What surrounds the nodules?
4. What is your diagnosis in this case?
5. What is the prognosis in this case?

CASE 6

History:

A 66-year-old man had been complaining of back pain for the past 5 months, for which he had taken non-steroidal anti-inflammatory medications, but the dull pain persisted. On physical examination he has no abnormal findings. Radiographs of the spine and pelvis show lytic bone lesions at T11, T12, L2, and in the right posterior iliac crest. A radiograph of the skull shows multiple lytic lesions. His CBC shows Hgb 10.8 g/dL, Hct 32.2%, MCV 89 fL, platelet count 135,000/microliter, and WBC count 4890/microliter. A serum chemistry panel shows sodium 140 mmol/L, potassium 4.0 mmol/L, chloride 98 mmol/L, CO2 24 mmol/L, urea nitrogen 32 mg/dL, creatinine 2.9 mg/dL, glucose 79 mg/dL, calcium 11.6 mg/dL, phosphorus 2.2 mg/dL, AST 30 U/L, ALT 23 U/L, alkaline phosphatase 249 U/L, total bilirubin 0.9 mg/dL, albumin 3.5 g/dL, and total protein 9.6 g/dL. A urinalysis shows sp gr. 1.020, pH 6.5, and no glucose, protein, or blood. A posterior iliac crest bone marrow biopsy is performed.

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Questions:

1. What is the predominant cell type present in the bone marrow?
2. What other laboratory studies should be done in order to arrive at a definitive diagnosis?
3. What is your diagnosis in this case?
4. What biotherapies are available?

CASE 7

History:

A 39-year-old man is known to be HIV positive and has had bouts of Pneumocystis carinii (jirovecii) pneumonia in the past two years. He was recently diagnosed with cytomegalovirus retinitis. He has been on highly active anti-retorviral therapy (HAART) that included zidovudine (AZT) for one year, but had to stop. He has experienced worsening abdominal pain for the past 2 days. On physical examination he has diffuse abdominal tenderness, abdominal distension without a fluid wave, and diminished bowel sounds. A plain film radiograph of the abdomen shows no free air, but there are dilated loops of bowel with air-fluid levels. An abdominal CT scan shows several 1 to 3 cm masses involving distal small bowel. A laparotomy is performed and a 20 cm segment of ileum is resected.

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Questions:

1. What is the predominant cell type in this mass lesion?
2. What is the diagnosis and how does this relate to his history?
3. What would a peripheral lymphocyte count (with subsets) probably demonstrate?
4. Why did he have to stop the zidovudine?

CASE 8

History:

A 60-year-old woman has had worsening nausea and vague epigastric abdominal pain for the past 6 months. She has tried taking calcium containing antacids without relief. She does not report hematemesis. On physical examination there are no abnormal findings. Laboratory studies show Hgb 13.5 g/dL, Hct 43.7%, MCV 87 fL, platelet count 303,600/microliter, and WBC count 8050/microliter. An upper GI endoscopy is performed and there is diffuse erythema of the gastric mucosa along with a 3 x 4 cm area of nodular, raised antral mucosa that lacks rugal folds and has focal erosions. Biopsies are taken. A CT scan of the chest and abdomen shows focal antral thickening, but no lymphadenopathy, hepatomegaly, or splenomegaly. A bone marrow biopsy is unremarkable. She has a positive urea breath test.

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Questions:

1. What is the organism identified in adjacent gastric mucosa?
2. What is the diagnosis?
3. How does this lesion arise?
4. How could her illness be treated?