65 yrs old male: submandibular node was biopsied in stomatology dept. with suspition of hematological disease (fever).  
HISTO:Hyperplastic II follicles with attenuated mantle zones and expanded T zone with HEVs and admixture of B immunoblasts. Cytological atypia is minimal.  
IH 1: Ki67 up to 40% (interfollicular); No T Ags lost. CD21/CD23 slightly irregular, but retained FDC network. PD1+ stronger in FC than in between. CD30+ polymorphic immunoblasts in the T zone.  
 
IH 2 (INCIDENTAL): In CD5 stain CD5dim/Bcl2 dim+ population in the mantle zone was noted: CyclinD1+ (mantle pattern and maybe slight infiltration outside)!!!  
 
MOLECS: IgH/IgK clear clone. TCR no definite clone (not enough sensitivity to differentiate). EBER+ grouped immunoblasts in the interfollicular space.  
 
PROPOSAL: Early immunoblastic EBER+ angioimmunoblastic T lymphoma (pattern I)+ incident B mantle cell lymphoma (early vs MCL in situ).  
Dif Dx: just MCL (mantle pattern or in situ)+ EBER+ reactive component.  
 
Thank you for beeing so close.

tzankov 2014-06-27 17:34	I miss EBER and CD30.     MCL with IS pattern is sure - the patient must be staged by means of CT, FACS of the PB (MCL?) and bone marrow biopsy to exclude MCL IS in that particular lymph node as a "top of an iceberg" of a systemic MCL.     PD1 only weakly stains extrafollicular T-cells and might a marker of exhausted (post-viral/post-vaccinational or post-whatever... the patient had fever! why? virus? did the stomatologist suspect a hematologic disease because of fever or did the patient had somethink else?) T-cells. I do not see patent sinuses, nor FDC prolifertiosn outside B-cell zones. I would not diagnose AITL, by no means, even if clonality detects a T-cell clone (could be post-viral or post-whatever).
ugnius 2014-06-27 20:09	AILT was the first idea before staining. I agree that it's not enough. EBER will scanned in the next week. Finally I'm not quite sure does T zone expansion is related to minimal MCL or just "noise": viral/reactive, etc.
ugnius 2014-06-27 20:10	CD30 will be posted tomorrow. Apologies for a little chaos today.
ugnius 2014-06-28 11:24	PCR NEWS: IgH/IgK clear clone. TCR no definite clone. You are true.
ugnius 2014-06-28 11:31	CD30 is placed there. EBER will be scanned in Monday.
ugnius 2014-07-01 08:24	EBER is placed there: clusters (in part CD30+) and interstitial "immunoblasts" with nuclear positivity.
tzankov 2014-07-01 11:21	MCL IS is clear,   AITL can not be established,   the EBER+ cell groups are in deed a problem: could this be a virus reactivation due to immunosuppression or a reinfection, which caused fever and lymphadenopathy? I do not know. teh increased ymount of PD1dim+ exhausted lymphocytes might be a hint towards acute virus (re)infection. Serology (IgM/IgG) and virus load (PCR) might give an answer.   The patient must be staged and yearly followed not to miss a MCL.
ugnius 2014-07-01 11:50	Thanx. Agreement on: MCL (with full hematoevaluation when arrives) and probably reactive EBV+ lymphadenopathy component (must be cleared up).
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