We present here an interesting case of lymph node along cystic duct, routinely taken for examination during the section of the gall bladder in a 65-year-old Bosnian male.  
On gross examination, lymph node did not exibit any changes.  
Microscopically, in paracortical areas of the lymph node proliferation of large, atypical lymphocytes with prominent nucleoli was noticed (immunoblast like cells). These lymphocytes had abundant cytoplasm, which was mainly eosinophilic. The same picture with atypical lymphocytes were seen in surrounding fat tissue (see Fig. 6).  
Additional immunohistochemical analysis revealed that lymphocyted exibited positivity for CD20 and bcl-2, focally for CD10, CD38, lambda and IgM whereas bcl-6, CD3, CD5, CD30, CD43, cyclin D1 and cytokeratin were negative.  
From patient's history we found out that he suffered of unresectable pancreatic carcinoma.  
Diagnosis: Malignant lymphoma or paracortical hyperplasia?  
Please, give your opinion!

Mueller-Hermelink 2007-06-28 22:23	I consider this process as a pathologic form of hyperplasia.However , I am not absolutely sure since I have difficulties to evaluate the Bcl 2 stain. In principle this is florid follicular hyperplasia where the proliferation goes over the margins of the follicle and merges with extrafollicular activation . The follicular structure can be well seen in CD 38 stain. The strong Bcl2 reaction in the deeper areas of the pulp are clearly positive . However , regular follicular hyperplasia should be negative. I do not know whether this slight positivity is due to overstaining . If it is true the process could be an early transformation. Since, however there is no infiltration of capsule , the process appears to be localized and partially involving the node I believe it is reactive .
SergeyN 2007-06-30 11:23	CD21/23/35 could be useful to visualise the follicular architecture. Did you stain for Ki67 and CD30?     Overall, it looks more like reactive, but there could be surprises, particularly if there are tumour masses elsewhere. Are there some significant changes in blood values?
anpo 2007-07-02 20:04	I agree that although by morphology the lympho node may be reactive the bcl-2 staining is disturbing - maybe it is overstained and should be repeated with more diluted antibody? How does a reactive GC look like with your staining?
FFalko 2007-07-03 11:32	It is a little hard to judge the process without seeing the overall architecture of the node, but I agree that the general impression still speaks for an atypical reactive process. If the blasts are indeed bcl-2 positive, however, this would be a very strong argument for partial infitration of the node by a large B-cell lymphoma. If available, CD21, CD43, IgD should be helpful to better delineate the architectural features.
hurwitz 2007-07-05 19:33	I share the worries of my collegues. Evaluation of Bcl2 is difficult and it might be worth repeating. Lambda seems to be weakly but truly+ on the large cells, information about kappa is missing. could you please ad an image of a kappa stained section?   Do you have the possibilty for clonality assessment by PCR?
hurwitz 2007-07-08 22:24	Dr.Vranic informed me that the diagnosis of atypical reactive hyperplasia has been accepted and no further investigations are planned.
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