Summary of the Case  
 
 
A 16 years old male patient was referred to us from the surgical side about 8 months back with a right axillary lymph node biopsy report of "Hodgkin’s lymphoma, lymphocytic predominance type". An FNAC from an adjoining LN, also done outside prior to the bx, was reported as NHL, which while reviewing, we found a classical RS cell around plenty of mature lymphocytes (Fig1). He presented to us with :  
– Multiple, slowly enlarging swellings in the right axilla for the last 6 years  
– Dull aching pain in the back – 6 months  
– Progressively increasing weakness of both lower limbs with difficulty in walking – 6 months  
– No h/o fever, night sweat or weight loss  
 
On examination, the patient was found to have significant right axillary and cervical lymphadenopathy, mild hepatosplenomegaly, mild pallor and kyphosis of spine with bony tenderness over D12 vertebra; the power of his lower limbs were Grade 4/5 on both sides with absent knee-jerk bilaterally. There was no sensory deficit on both lower limbs or any bladder/ bowel abnormality.  
 
History and examination done to rule in radiculopathy and Koch’s infection (common in our country) were not informative.  
 
We reviewed the lymph node biopsy slides and diagnosed it as Classical HD,lymphocyte-rich variant - there were plenty of mononuclear Hodgkin cells and quite a few Classical RS cells against a background of mature lymphocytes; no L&H popcorn cell was found(Figs 2-5). We sent the paraffin blocks for immunohistochemistry at an outside institute since this facility is not available with us. Meanwhile we did a serum LDH which was raised. We also did X-Ray DL Spine, CT scan of chest & abdomen as also an MRI of DL spine. They revealed erosive changes of D12 vertebra with pre- & paravertebral soft tissue shadowing and evidence of cord compression(Figs 6,7). We did an FNAC from the paravertebral soft tissue mass where we found large, atypical mononuclear and binucleated cells (Fig 8,9).This was followed by a biopsy of the same mass which was initially reported by the pathologist as “suggestive of deposit of lymphoma”. I reviewed the slides, found a classical R-S cell , brought it to the notice of the histopathologist who immediately acknowledged my finding (Figs 10,11). A bone marrow biopsy done revealed features suggestive of infiltration by lymphoproliferative disorder; no R-S cell was found in it. At this stage we diagnosed the patient to be suffering from HD, classical lymphocyte-rich variant, Stage IV and eagerly waited for the immunohistochemistry results. Finally the report came which went like this:  
Tumour cells- CD20+,CD30-(repeated twice),CD15- & LCA-ve. Background cells are CD3+. Although the R-S cells are CD30 & 15- in this case, this is unlikely to be anything other than classical HD.  
(I do not have the immuno-stained slides; but I have the paraffin block of the LN Bx. I also have the H&E slides of the paravertebral mass and the marrow trephine Bx with me. No other slide or paraffin block is available with me.)  
So now we had a lymph node biopsy of HD whose H&E was suggestive of classical lymphocyte-rich variant while the immunohistochemistry was in favour of lymphocyte predominant HD. We started to treat the patient with ABVD regimen. While he was responding well to therapy, he stopped coming back to us after completion of 4 cycles because of economic constraints.  
My question: What is the diagnosis in this case? - the H&E suggests HD Classical Lymphocyte-rich variant while the immunohistochemistry is in favour of Lymphocyte predominant HD though the H&E findings were given more importance even in that report  

aorazi 2006-07-08 04:01	Interesting case. However, it is impossible to say anything conclusive without reviewing the original histology under the microscope. The fig. 2LN 1JPG is particularly essential and, as it stands now, it is useless being totally out of focus. So it is impossible to appreciate an eventual paragranuloma like nodular architecture (LP-HD) or the eventual presence of a mantle zone distribution of the RS cells (lymphocyte rich HD). I think the latter diagnosis, however, is pretty much ruled out by the immunohistochemistry results -- who obviously need to be shown to the group. The differential diagnosis --if the immunos. results are correct -- taking into consideration the morphology I can see, is between a T-cell rich B cell lymphoma with RS-like cells and an LP-HD, which I think is less likely in view of the diffuseness of the proliferation (again the fig. 2LN 1JPG prevents any conclusion to that regard) and also by the lack of popcorn cells that you describe. Suggestion: borrow the immunos. or at least digital images and review them carefully in the light of the morphology.
anpo 2006-07-08 17:07	Morphology is not easy to appreciate on all photos but I agree with Dr Orazi - morphology, immunophenotype, spread of the disease (especially bone marrow involvement) is in favour of T-cell / histiocyte rich variant of diffuse large B-cell lymphoma. Lymphoma cells in these cases often mimic R-S cells. However, some studies suggest that there may be a gray zone between T-cell rich NHL and nodular LP of Hodgkin lymphoma (see Blood. 2003 Nov 15;102(10):3753-8)and some patients who start as NLPHL may develop T-cell rich NHL. Long history of lymphadenopathy in this patient may suggest this possibility.
sirje 2006-07-09 14:26	The low power shows diffuse pattern of the lymphoma. Principally the large cells are distributed evenly. There is no signs of nodular pattern. Aggressive behavier (vertebral erosive changes, soft tissue infiltration, hepatosplenomegaly), is not usually characteristic for NLPHD. I agree with Dr. Orazi and Dr.Porwit supporting the T cell rich B cell lymphoma diagnosis, also possible development from NLPHD.
hurwitz 2006-07-09 16:57	I agree with the comments of Attilio, Anja and Suurje. The images are not optimal, most of them are out of focus.However the available morphology, the results of the immunohistochemstry and the clinical dat ( tumor spread extranodal and BM involvement ) are srongly in favour of TCRBCL with Hodgkin like cells, which is not unusual.   If possible we would appreciate some intermediate power (20x) images to see if there is any nodularity, and also if possible, as Attilio suggested try to borrow the immunnohistochemistry and send us some images.
dakudr 2006-07-12 15:55	I wish to thank all members of the group for taking so much interest in my case. The possibility of T-cell rich B-cell lymphoma did occur in my mind after getting the immuno report but the prolonged duration (6yrs)compelled me to rule that out. Yet I was not fully convinced and that's the reason I am now in the group. I would like to thank Dr Orazi for his kindness in accepting the LN Bx block for immuno as also a review of the H&E slides. I am going to send them to him soon. Meanwhile let's keep our fingers crossed and wait for the results. Lastly I thank Dr Hurwitz for co-ordinating the whole thing so well.With her zeal, hope our group continues to get richer by the day.
	» Add comment (Login)