The SECOND subcutaneous lymph node biopsy was done for 69yrs old lady with DGN.: DLBCL, established histologically in 2005 (biopsy of the tonsil). After DLBCL diagnosis the standard treatment with multiple CHOP was performed. Due to HCV suspition liver biopsy is planned.  
HISTO: on the photos (LN- lymph node; T- PIRMARY tonsil biopsy). LYMPH NODE: The vague nodular and diffuse infiltrate consists of small- medium and single large monocytoid and plasmacytoid cells with oval nuclei. TONSIL: Exulcerated tonsil with diffuse infiltrate consisting of diffuse infiltrate of medium- large sized cells, some with vesiculated irregular nuclei and amphophylic nucleoli. A lot of apoptotic bodies are present. The plasmacytes are present.  
IH: on the photos with the same abreviations. LYMPH NODE: CD23+ disrupted FDC network with rudimentary Bcl6+ follicular center cells and Mum1+ activated cells and plasmocytes. The infiltrate: CD20+, CD43- (some larger cells maybe +), CylinD1-. Ki67+ fraction about 20% with exception of rudimentary follicular center with higher activity.  
TONSIL: CD20+ population with EMA/Mum1+ plasmacytes. Some cells Mum1+ are with irregular large nuclei, single p53+ cells. Ki67 fraction is higher than in lymph node- about 50-60%. EBV LMP1(-). Bcl2 positivity in the large cells is lower then in lymph node (low grade component). Single groups of Bcl6 probably represent the rest of follicle center cells. CD23 network is totally absent. Some CD30+ atypical cells with lobated nuclei.  
DIAGNOSIS 2 (LN): B marginal zone lymphoma.  
REVISED DIAGNOSIS 1 (tonsil): DLBCL???  
Thank you for collaboration.

franco 2006-04-10 15:15	I agree with your interpretation. DLBCL in the tonsil, marginal zone lymphoma in the recurrent lesion. Composite (low and high grade) lymphomas are generally believed that occur as a progression of a indolent lymphoma. However, it is possible a simultaneous detection of low and high grade lymphoma. We are just in the opposite case, low grade after therapy for high grade lymphoma. Two possible explanations: 1) Two different clones; 2) The same clones (in that case low grade component should have co-existed at the time of the first diagnosis).   It is also important the HCV positivity which is frequently detected in association with marginal zone lymphoma, at least in our Country.
ugnius 2006-04-10 16:03	Thank you dr.Franco. If the liver biopsy will provide some add info I will inform you.
ugnius 2006-04-10 16:04	One more quest: what limits of Ki67 expression you use for discrimination between LOW and HIGH processes (NHL). Where is the LOWER limit of Ki67 for DLBCL? Thank you in advance.
dirnhofer 2006-04-11 12:42	basically, i agree with your dx and vito francos interpretation. most likely comosite lymphoma; typically, after therapy, the low grade (more differentiated) part, persists while the high grade part is chemosensitive (similar to germ cell tumors). had recently a similar case of fl after therapy for initial dlbcl with genetically proven clonal relationship.   alternative explanations would be relapse of dlbcl with somewhat altered morphology and proliferation fraction (due to therapy) or two independent lymphomas, not clonally related at all.     for ki67: there is now accepted treshold for high grade and according to who-classif., low and high grade should not be used anymore; nonetheless, for dlbcl, at least 20% would probably be necessary (excluding therapy effects, e.g. rituximab mainenance etc)
ugnius 2006-04-11 20:11	Thanx. But I'm still in doubt can you ever to propose primary DLBCL diagnosis wiith Ki67 fraction 20%?   The patient really was treated with interferon due to HCV (add info).
ugnius 2006-04-13 18:24	...And if you enlarge LN cells you may see couple of mitoses. Ki67 prolif. activity is not so high, but...   I've applied additionally CD30 on tonzil- there are some giant cells with lobulated nuclei positive. The plasma cells in tonsil are more Ig kappa +, than lambda. Photos will be appended tomorrow. Thank you in advance for add comments.
ugnius 2006-04-14 12:40	Add: kappa and lambda on plasma cells.
ugnius 2006-04-14 12:52	Ig kappa is slightly predominating in both places: tonsil and lymph node.
dirnhofer 2006-04-17 15:49	20% ki67 is probably the lowest treshold - bust still, a dx of dlbcl is not made on the basis of ki67 but on the presence of diffuse sheets of b-blasts!   k and l do not help in this case
hurwitz 2006-04-21 09:30	I fully agree with the comments of my collegues Vito and Stephan. Particularily Sephans' last comment is of utter importance: The diagnosis of DLBCL is not to be based on Ki67!!!!! Ki67 can provide additional useful information, but it cannot be used as diagnostic criterion. It is an improtant criterion for delineating Burkitt or Burkitt like lymphoma from DLBCL.   Kappa > than lambda on plasma cells is a normal finding.   A question: do you perform routine Bone marrow biospies for staging of lymphomas. If yes it might be worthwhile to go back to the biopsy, to see if a low grade component is present in the biopsy, which can be seen in some of the cases.
ugnius 2006-04-21 12:13	Thanx dr.Nina. BM biopsy was performed after DLBCL treatment, si I've found only serous degeneration and panhypoplasia, maybe due to therapy. So we have not yet lymphoma form BM. Maybe it will be repeated in future.
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