68 yrs old female with clinical diagnosis DLBCL (after chemotherapy). Threpine biopsy.  
HISTO: BM with cellularity to 80% and 70% focal and diffuse interstitial infiltrates consising of small- medium basophilic cells with oval slightly eccentric nuclei. Focal I° reticular fibrosis. Some large histyocytic cells in hypocellular areas with eosinophilic coarse granules in cytoplasm.  
IH: CD138+ single plasmacytes (normal)(<5%).  
TUMOR: CD138(-), CD20(+++) 100%, CD79a 50% (++), CD56/CD23/Bcl 6/Bcl 2(-), Mum1 (+/++) 30%, CD3(-)(except T lympho's), CD10(-), Ig kappa (+++) 50%, Ig lambda (-).  
CD68 reaction on large eosinophilic cells is uninformative (hypocellular areas disappear in serial sections).  
WORKING DIAGNOSIS: High grade lymphoma: anaplastic myeloma CD138 (-) vs DLBCL with crystaline hystiocytosis.  
QUESTION: Histological criteria for discrimination of anaplastic "plasmoid" (by HE or IH) lessions.  
Cytollogical quality is SUBOPTIMAL. A lot of appologies.  
PRIMARY PULMONARY? TUMOR (2004 consultation case with clin. dgn. "Central tumor in upper pulmonary lobe"): The moderatelly cellular "clear" (T lymhoma like) infiltrate of the atypical medium- large CLEAR and EOSINOPHILIC cells with high proliferative rate and CB like cytology. The necrosis and vascularity are promiment. Single giant cells with nuclear lobulations.  
IH PRIMARY: CD20+, CD30-, CD3-. PanCK-, CD99- (In 2004 IH panel was more narrow than nowadays).  
NOTE: Old parafinn blocks are not avalable now.  
Thank you for collaboration.

sirje 2006-08-10 08:23	It seems to be a lymphoblastic type of infiltration with high proliferation rate. What about flow cytometry, TdT, CD34, CD10? PB values? Lymph nodes, spleen?
ugnius 2006-08-10 09:21	Dear dr.Sirje, I've requested add data from hematoLab. CD34/TdT pending. I will inform you immediatelly. It's strange, that visually (HE) only scattered apoptotic bodies are present. There is any signs of high proliferative rate- only in Ki67 stain.   NOTE: In ourlab kappa/lamba are working practically only with PLASMOID cells, so it was strong argue (for us, for sure:))...
anpo 2006-08-10 11:41	I think that the cells are too large to be lymphoblastic and the proliferation is not near 100% which is against Burkitt-like. I would favor the diagnosis of DLCB with Activated B-cell phenotype (CD10-/Bcl6-/Bcl2-/Mum-1+). Some of these DLCBs may have a strong expression of cytoplasmic Ig without being plasma cell tumors.
ugnius 2006-08-10 15:10	Add info: 2004 DLBCL was diagnosed from pulmonary (mediastinual?) surgical biopsy. Additional photos will be placed in right now.
ugnius 2006-08-10 15:11	Your comments on the meaning of "macrophages" would be of value too. Thanx.
ugnius 2006-08-10 16:22	Primary tumor pictures are placed in. It seems DLBCL with spreading to BM. But "face" of the tumor in BM, Ig kappa expression and macrophages with Ig??? deposits are quite attractive by our opinion.
ugnius 2006-08-10 16:23	FLOW: Ig kappa:lambda 4:1, CD45+, CD11c+, CD19+, CD20+, CD22+, CD25+, CD38+, HLA-DR+, FMC7+, CD5-, CD10-, CD23-.
ugnius 2006-08-10 16:24	BM tumor cells maybe are "retracted" and smaller than primary with resemblance with "plasmoid" or "blastoid" cells with not prominent proliferative activity on HE slides.
ugnius 2006-08-10 16:31	Rudimentary pigmentation and residual lymphoid follicles sugest maybe tumor was located in mediastinal lymph nodes?
dirnhofer 2006-08-10 18:24	this is a dlbcl (with immunoblastic/plasmacytoid morphology). morphology, strong cd20 and lack of cd138 clearly argue against mm.   macrophage accumulation can be due to ig-production of tu cells (cristalloid structures, but of course also many other reasons...)
ugnius 2006-08-10 18:32	Thank you dr.Stephan. It's sad, that with exception of BM I cannot apply Mum1, Bcl6, CD138/CD68 and Ig for primary tumor.
ugnius 2006-08-11 13:28	CD34/TdT completelly negative on BM.
kremer 2006-08-14 11:08	I aggree totally with Doctor Dirnhofer; this is a DLBCL in the BM
hurwitz 2006-08-15 18:46	I agree with the opinions of my collegues, this is a DLBCL, in particular I share Anjas opinion, that the strong positive reaction with kappa is not an argument for a plasma cell tumor. Some of the tumor cells have prominent central nucleoli and a rim of basophilic cytoplasm consistent with immunoblasts with plasmacytoid differentiation, which may explain the strong positivity for kappa.   The numerous granulated macrophages in the bone marrow are consistent with sea blue histiocytes, which can be seen in the bone marrow in conditions,associated with increased cell turnover such as hemolytic anemias, MDS, AL, and lymphomas. For confirmaton I would suggest the following stains: PAS, ZN, Gie.
ugnius 2006-08-16 08:51	Thank you! 1. About kappa- for sure it's more typical restriction for lymhomas, but in my enviromnent Ig kappa/lambda usually DON'T WORK AT ALL on lymphomas:)   2. I cannot resolve "macrophageal" problem due to dissappearing from the sections. Idea of "sea blue" is very good.
cancerr 2006-08-16 21:01	The patient presented with anterior mediastinal mass and responded to anthracycline based chmotherapy. She relapsed 1,5 years later in bone marrow. The clinical presentation and relapse pattern (organ rather than lymphnode) is consistent with the diagnosis of primary mediastinal DLBCL.
ugnius 2006-08-17 15:44	The last IH: LCA (-/+, minority of the cells), ALK1-.
ugnius 2006-08-25 12:52	I've found nice picture of pseudo Goshe cells in BM (myeloma case). attachment: fulltext.pdf
hurwitz 2006-08-26 23:08	In fact sea blue histiocytes and pseudo gaucher cells do occur in the bone marrow in similar conditions associated with increased cell turnover, however the material stored in their cytoplasm is different. Glucocerebrosides in pseudogaucher cells and ceroid and lipofuscin in sea blue histiocytes.
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