61 yrs old woman with diagnosis of NHL ("marginal zone lymphoma" after flow): consultation case.  
HISTO: please find virtual slide.  
IH: CD20+ CD5- CD23+ CD43- aberant expression in follicles and interfollicular and extranodal small lympho's. Follicles: CD10+; Bcl6+/-(maybe rudimentary FC cells) CD23+. Some follicles with clear "marginaloid" zone and colonisation features.  
FLOW: CD5- FMC7+.  
 
PROPOSAL: Low grade B NHL: FL?MZL? with aberant CD23+ vs CLL with exuberant colonisation of follicles?  
Special quest: CD10 and CD23 in follicles?  
Thank you for participating.

hurwitz 2008-04-10 20:38	Sorry, perhaps I am doing something wrong, the moment I try to enlarge the image goes out of focus and no details can be seen.
diane.c.farhi 2008-04-10 22:18	I can't see anything at all.
ugnius 2008-04-11 08:50	It takes a little time to adjust sharpness (it depends on the internet connection speed). I will ask Kurt to test it once more. This file must be opened automatically without any special programs. For sure, it's possible to install free software from for reviewing (http://www.aperio.com/download.asp)   Anyway I will append "classic" photos for clarity.
kurt 2008-04-11 09:43	I have no problem seeing the virtual slide. Am using FireFox browser on a Mac.
diane.c.farhi 2008-04-11 18:12	I see a follicular pattern here, with follicular cells showing these results: CD5-, CD10+, CD20+, CD23+, FMC7+ (by flow), bcl6 +, bcl2+, IgD+, IgM+. The interfollicular area probably has a mix of clonal B-cells, other B-cells, and T-cells. The perinodal infiltrate shows a mix of B-cells (probably clonal) and reactive T-cells. I would call this a follicular lymphoma, low-grade or grade 1. In answer to your question about CD10 and CD23, in my experience follicular lymphomas are normally positive for CD10 and CD23.
tzankov 2008-04-14 12:33	I would also classify this case as FL. Indeed, in the bcl-6 stain, one can suspect "colonization" by bcl-6-negative cells, but the bcl-6 stain is a very inconsistnt one ond should be interpeted only with respect to CD10, bcl-2 and CD23. I also acknowledge that there are too few CD10+ cells outside the follicles, which could be another argument against FL, but the huge amount of CD23+/CD5- cells outside the lymph node are strong arguments for FL.
ugnius 2008-04-14 18:33	Thank you.   1. CD23+ reaction is described as aberant, but not a typical one in ordinary FL (at least in my mind:)).   2. Additionally extranodal infiltrate consists of small lymphos and somtimes CLL is CD5-.   3. Interfollicular infiltrate shows evenly similar CD20+ reaction compared with follicles (argue contra CLL).
SergeyN 2008-04-16 17:59	Just a thought: are follicules CD43 negative?   And another: sometimes characteristic Ki67 pattern is partially retained in the colonised follicles.     Personally, I think that both the lesion structure with large follicules and narrow interfollicular spaces and bcl2/strong CD20 positivity are rather unusual for CLL colonisation. MZL is a theoretical possibilty (if we consider the follicules to be only partially CD10 positive, but in our lab normal lymph nodes often stain this way :) ). All the rest favours FL.
hurwitz 2008-04-21 19:32	For me this is a straight forward FL, grade I. CD23 expression in FL is not aberrant, it has been observed in a large number of cases {PMID: 17493235},{PMID: 18036173},{PMID: 18359244}
hurwitz 2008-04-21 21:21	Final diagnosis:     Follicular Lymphoma, grade I
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